Depression - antenatal and postnatal

Source:
Clinical Knowledge Summaries
Publication date:
01 November 2018

Abstract

Depression - antenatal and postnatal Last revised in November 2018 Next planned review by December 2023 Summary Back to topDepression - antenatal and postnatal: Summary Depression refers to a spectrum of mental health problems characterized by the absence of positive affect (that is a loss of interest and enjoyment in ordinary things and experiences), low mood, and additional emotional, cognitive, physical, and behavioural symptoms.Women who are pregnant or postnatal can develop or have the same mental health problems as other adults.Depression in the postnatal period can occur at any time within a year after birth.Common misconceptions about depression in the postnatal period are that symptoms and effects are less severe than depression at other times, it will go away by itself, and that it is entirely due to hormonal changes.The possibility of depression should be assessed at a pregnant woman's first contact with primary care, at her booking visit, and postnatally.The usual diagnostic criteria for depression should be followed for depression in the antenatal and postnatal periods.Decisions about treatment should be made on an individual basis, taking into account the risks and benefits of the options available to the woman. The woman, and her family where appropriate, should be involved in all decisions about treatment.Treatment options depend on the severity of depression and include no intervention ('watchful waiting'), psychological treatment, antidepressant treatment, or a combination of psychological and antidepressant treatment.Women requiring psychological treatment should normally be assessed within 2 weeks of referral and seen promptly for treatment (ideally, within 1 month of initial assessment).There are no antidepressants licensed specifically for pregnant women.In a woman being treated for depression who becomes pregnant, it is recommended that specialist advice is sought before stopping or switching antidepressant treatment.In a woman with a new episode of antenatal depression, it is recommended that specialist advice is sought before starting, stopping, or switching antidepressant treatment.Specialist advice may be sought ideally from a specialist perinatal mental health team, where available; or from a secondary mental health service; or the UK Teratology Information Service (UKTIS) on 0344 892 0909. There are no antidepressants licensed for breastfeeding women; however, if psychological treatment is unavailable or unacceptable, or symptoms are severe, antidepressants are an option.In a postnatal woman with depression it is recommended that specialist advice is sought (ideally from a specialist perinatal mental health team, where available; or from secondary psychiatric care) before starting, stopping, or switching antidepressant treatment, particularly if the woman is breastfeeding. Antidepressant treatment should be discussed with a paediatrician if the if the baby was premature or has health problems or liver or kidney impairment.Sertraline and paroxetine are the selective serotonin reuptake inhibitors of choice for a woman who is breastfeeding.Imipramine and nortriptyline are the preferred tricyclic antidepressants in breastfeeding. Doxepin should be avoided. Have I got the right topic? Back to topHave I got the right topic? From age 18 years to 60 years (Female).This CKS topic is based mainly on the clinical guideline Antenatal and postnatal mental health: clinical management and service guidance published by the National Institute for Health and Clinical Excellence [National Collaborating Centre for Mental Health, 2014; NICE, 2014]. This CKS topic covers the management of pre-existing or newly diagnosed depression in pregnancy and the management of depression in the postnatal period, including in women who are breastfeeding.This CKS topic does not cover the prevention of depression in pregnancy or the postnatal period. It also does not cover the management of other mental illnesses in pregnancy or the postnatal period.There are separate CKS topics on Bipolar disorder, Depression, Eating disorders, Generalized anxiety disorder, Insomnia, Pre-conception - advice and management, and Psychosis and schizophrenia.The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care. How up-to-date is this topic? Back to topHow up-to-date is this topic? Back to top Changes Changes September to November 2018 — reviewed. A literature search was conducted in September 2018 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. A new section on prognosis has been added. There have been no major changes to recommendations, however, assessment, diagnostic, and management recommendations have been updated in line with the NICE Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Detail on the risks of individual antidepressants in pregnancy and breastfeeding has been removed and links to specialist sources of information included. Prescribing information specifically relevant to antidepressants in the antenatal and postnatal period is now included in the management scenarios. General antidepressant prescribing information is available in the CKS topic on Depression. Back to top Previous changes Previous changes September 2015 — minor update. Typographical error corrected.July 2013 — minor update. Links to the DVLA website have been updated.June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.January 2013 — reviewed. A literature search was conducted in December 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of the topic. Due to conflicting data on the safety of antidepressants during pregnancy, CKS no longer make specific recommendations on antidepressant choices during pregnancy. CKS now recommends that specialist advice should be sought before starting antidepressant treatment in a woman with a new episode of antenatal depression, and before stopping or switching antidepressant in a woman who becomes pregnant whilst taking an antidepressant. No major changes have been made to the recommendations for managing breastfeeding women with postnatal depression; however, it is also recommended that the prescriber considers seeking specialist advice if considering antidepressant treatment for this group of women.October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.March 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. Issued in April 2012.May 2011 — minor update. The 2011/2012 QOF indicators have been added to this topic. Issued in June 2011.May 2011 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.March 2011 — minor update. The NICE quality standards for treating depression have been added. Issued in June 2011.March 2010 — minor update. Text added regarding the small increased risk of cardiovascular malformation associated with first trimester maternal exposure to fluoxetine. Issued in March 2010.May 2009 — minor update. Text added regarding the manufacturer's warning about the small increased risk of cardiovascular malformation associated with first trimester maternal exposure to paroxetine. Issued in June 2009.October 2008 — minor typographical correction.October 2007 to March 2008 — developed as a new CKS topic. The evidence-base has been reviewed in detail, and recommendations are clearly justified and transparently linked to the supporting evidence. Back to top Update Update Back to top New evidence New evidence Evidence-based guidelinesNo new evidence-based guidelines since 1 September 2018.HTAs (Health Technology Assessments)No new HTAs since 1 September 2018.Economic appraisalsNo new economic appraisals relevant to England since 1 September 2018.Systematic reviews and meta-analysesNo new systematic reviews and meta-analyses since 1 September 2018.Primary evidenceNo new randomized controlled trials published in the major journals since 1 September 2018. Back to top New policies New policies No new national policies or guidelines since 1 September 2018. Back to top New safety alerts New safety alerts No new safety alerts since 1 September 2018.  Back to top Changes in product availability Changes in product availability No changes in product availability since 1 September 2018. Goals and outcome measures Back to topGoals and outcome measures Back to top Goals Goals To support primary healthcare professionals to:Detect cases of depression in women during the antenatal and postnatal periods.Appropriately treat depression in the antenatal and postnatal periods.Refer or seek specialist advice for women with depression during the antenatal and postnatal periods, when appropriate. Back to top Outcome measures Outcome measures No outcome measures were found during the review of this topic. Back to top Audit criteria Audit criteria No audit criteria were found during the review of this topic. Back to top QOF indicators QOF indicators Table 1. Indicators related to depression in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract.IndicatorPointsAchievement thresholdsDepressionDEP003 The percentage of patients aged 18 or over with a new diagnosis of depression in the preceeding 1 April to 31 March who have been reviewed not earlier than 10 days after and not later than 56 days after the date of diagnosis.1045–80%Data from: [BMA and NHS Employers, 2018] Back to top QIPP - Options for local implementation QIPP - Options for local implementation No QIPP indicators were found during the review of this topic. Back to top NICE quality standards NICE quality standards NICE has specified the following quality standards for antenatal and postnatal mental health.NICE QS115 Antenatal and postnatal mental health:Statement 1. Women of childbearing potential are not prescribed valproate to treat a mental health problem.Statement 2. Women of childbearing potential with a severe mental health problem are given information at their annual review about how their mental health problem and its treatment might affect them or their baby if they become pregnant.Statement 3. Pregnant women with a previous severe mental health problem or any current mental health problem are given information at their booking appointment about how their mental health problem and its treatment might affect them or their baby.Statement 4. Women are asked about their emotional wellbeing at each routine antenatal and postnatal contact.Statement 5. Women with a suspected mental health problem in pregnancy or the postnatal period receive a comprehensive mental health assessment.Statement 6. Women referred for psychological interventions in pregnancy or the postnatal period start treatment within 6 weeks of referral.Statement 7 (developmental). Specialist multidisciplinary perinatal community services and inpatient psychiatric mother and baby units are available to support women with a mental health problem in pregnancy or the postnatal period.[NICE, 2016] NICE QS37 Postnatal care:Statement 9. Women have their emotional wellbeing, including their emotional attachment to their baby, assessed at each postnatal contact.Statement 10. Women who have transient psychological symptoms ('baby blues') that have not resolved at 10–14 days after the birth should be assessed for mental health problems.Statement 11. Parents or main carers who have infant attachment problems receive services designed to improve their relationship with their baby.[NICE, 2013] Background information Back to topBackground information Back to top Definition What is it? Depression refers to a spectrum of mental health problems characterized by the absence of positive affect (that is a loss of interest and enjoyment in ordinary things and experiences), low mood, and additional emotional, cognitive, physical, and behavioural symptoms [National Collaborating Centre for Mental Health, 2010]. Women who are pregnant or postnatal can develop or have the same mental health problems as other adults [National Collaborating Centre for Mental Health, 2014]. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria specify that for peripartum depression onset is during pregnancy or within 4 weeks after delivery [American Psychiatric Association, 2013]. However, there is general agreement that onset can occur any time within the first year [SIGN, 2012; Langan and Goodbred, 2016; BC Reproductive Mental Health Program, 2014; Ford et al, 2017].   The National Collaborating Centre for Mental Health advises caution in the use of the term 'postnatal depression' as it can be misused to include any mental illness occurring postnatally, and may result in other serious illnesses failing to be identified. Common misconceptions about depression in the postnatal period include that [National Collaborating Centre for Mental Health, 2014]: Symptoms and effects are less severe than depression at other times.It will go away by itself.It is entirely due to hormonal changes.It is different from depression present before childbirth.There is no risk of recurrence in the non-postnatal period. Back to top Risk factors What are the risk factors? Risk factors for antenatal depression include:Prior depression.Maternal anxiety.Life stress.Lack of social support.Childhood abuse.Domestic violence.Unintended pregnancy.Relationship factors.Risk factors for postnatal depression include:Past history of depression or anxiety, including during pregnancy.Baby blues. Family history of depression.Lack of social support.Poor partner relationship.Preterm birth, infant health problems, need for neonatal intensive care.Parents' perceptions of their own upbringing.Unplanned pregnancy.Unemployment.Not breastfeeding.Antenatal parental stress.Antenatal thyroid dysfunction.Longer time to conception.Depression in fathers.Having two or more children.Current, or history of, substance misuse [Ross and Dennis, 2009].[SIGN, 2012; BC Reproductive Mental Health Program, 2014; RCGP, 2016; Kendig et al, 2017; McAllister-Williams et al, 2017] Back to top Prevalence How common is it? Most mental health problems are as common in the perinatal period as they are at other times of life [NHS England and NHS Improvement, 2018]. Depression is under-recognised during pregnancy and postnatally [NICE, 2014].  In pregnancy, depression and anxiety are the most common mental health problems, affecting around 12% and 13% of women, respectively [NICE, 2016].   In the first year after birth, around 15–20% of women experience depression and anxiety [NICE, 2016].  There is evidence to suggest that perinatal depression may be commonly missed or undertreated in general practice [Ford et al, 2017].  Back to top Complications What are the complications? Severe depression is associated with an increase in [BC Reproductive Mental Health Program, 2014; National Collaborating Centre for Mental Health, 2014]: Obstetric complications.Sudden infant death syndrome.Low birthweight and premature infants.Self harm and suicide attempts — suicide is a more common cause of death in the peripartum period than hypertensive disorders or postpartum haemorrhage [Langan and Goodbred, 2016] and is now a leading cause of maternal death in the first year postpartum, although it is still rare [BC Reproductive Mental Health Program, 2014; Royal College of Psychiatrists, 2015].  Depression in pregnancy, particularly if not treated, may affect the cognitive, emotional, social, educational, behavioural, and physical development of the infant, although a minority of children are affected [MacQueen et al, 2016; RCGP, 2016]. Peripartum depression is associated with failure to thrive, attachment disorder, and developmental delay at a year old [Langan and Goodbred, 2016]. There is an association with depression in pregnancy and depression in adolescents and young adults [National Collaborating Centre for Mental Health, 2014]. Depression in the postnatal period may be associated with compromised mother-infant interactions [BC Reproductive Mental Health Program, 2014; O'Connor et al, 2016].   Women with severe depression or postpartum psychosis may, very rarely, harm their unborn child or newborn infant [BC Reproductive Mental Health Program, 2014]. Consequences for the family include the impact on the woman's partner and other children [SIGN, 2012; Royal College of Psychiatrists, 2015; Langan and Goodbred, 2016]. There is an increased risk of marital difficulties related to postpartum mental illness [Stewart and Vigod, 2016], and the woman's partner may also become depressed [SIGN, 2012; Jones and Shakespeare, 2014].  Back to top Prognosis What is the prognosis? There is a lack of evidence to suggest that the prognosis of mental health problems developing during pregnancy or the postnatal period is different from those occurring at other times of life. If depression is untreated during pregnancy, women have a seven-fold increased risk of postpartum depression compared with women with no antenatal depressive symptoms. Depression occurring postnatally is often self-limiting within a few months, however about one third of women are still unwell one year after childbirth, and about 13% after 2 years. The risk of subsequent relapse is high, affecting around one in four women.[National Collaborating Centre for Mental Health, 2014; Stewart and Vigod, 2016] Diagnosis Back to topDiagnosis of antenatal and postnatal depression Back to top Detection How do I identify people for further assessment? At a woman's first contact with primary care, or at her booking visit, and early in the postnatal period:Discuss her mental health and wellbeing and consider asking two questions to identify possible depression:During the past month, have you often been bothered by feeling down, depressed, or hopeless?During the past month, have you often been bothered by having little interest or pleasure in doing things?Regularly ask women about their current mental health during pregnancy and the postpartum period. Postnatally, ask about emotional wellbeing and whether symptoms of baby blues such as low mood, tearfulness, and anxiety have resolved at 10–14 days after birth. If depression is suspected from a positive answer to either of the depression identification questions, the woman is at risk of developing a mental health problem, or there is clinical concern, assess further in order to come to a diagnosis. For more information, see Assessment and Diagnosis.  Back to top Basis for recommendation Basis for recommendation Importance of detectionMeasures to detect depression in the perinatal period are important because there is a risk of mood disorders being undetected due to symptoms being attributed to normal pregnancy changes and the usual psychosocial adjustments occurring in the postnatal period [Kendig et al, 2017]. Prompt detection of postpartum depression can expedite treatment and reduce the impact on the woman's baby [van der Zee-van den Berg et al, 2017]. An evidence review commissioned by the National Institute for Health and Care Excellence (NICE) discussed the opportunities for healthcare professionals to identify women at risk of, or with a mental health problem in pregnancy or postnatally during the regular antenatal and postnatal contact usually arranged at this time. However, it noted that identification rates are low [National Collaborating Centre for Mental Health, 2014].  Depression identification questionsThe depression identification questions are recommended based on Antenatal and postnatal mental health: clinical management and service guidance published by NICE [NICE, 2014]. These two focused questions on mood and interest are practical for use in a primary care setting in pregnancy and the postnatal period and have been found in studies to have a sensitivity of 100% for ruling out depression during this time, although the questions had low specificity and a significant number of false positive results [National Collaborating Centre for Mental Health, 2014].The advantages of these questions include their brevity and convenience, that they do not require additional resources, and that they can be used by healthcare professionals who are not specialists in mental health in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014]. Asking about current mental health during pregnancy and the postpartum periodThe recommendations to ask women about their current mental health during pregnancy and the postpartum period reflect advice in a Royal College of Psychiatrists report on perinatal mental health services [Royal College of Psychiatrists, 2015] and the NICE guideline Postnatal care up to 8 weeks after birth [NICE, 2006a]. Further assessmentFurther assessment for certain groups of women is recommended based on Antenatal and postnatal mental health: clinical management and service guidance published by NICE [NICE, 2014].  Back to top Assessment How should I assess a women with depression in pregnancy or postnatally? If a woman responds positively to either of the depression identification questions, is at risk of developing a mental health problem, or there is clinical concern, consider:Using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of a full assessment (note that a positive screen on the EPDS is not the same as a diagnosis of depression), or If a severe mental health problem is suspected, referral to a mental health professional. To help to assess and diagnose a suspected mental health problem in pregnancy or the postnatal period, ask about:History of any mental health problem (particularly depression, postpartum psychosis, or bipolar disorder), including in pregnancy or the postnatal period, treatment received, and response; family history of mental health problems in a first-degree relative.If a woman has any past or present severe mental illness or a family history of severe perinatal mental illness in a first-degree relative, be alert for possible symptoms of postpartum psychosis in the first two weeks after childbirth. Any worries or preoccupations.The woman's attitude towards the pregnancy (including denial of pregnancy), her experience of pregnancy, and any problems encountered by her, the fetus or the baby.If postnatal, the relationship between the woman and her baby (including features such as verbal interaction, emotional sensitivity, and physical care), and the baby's health, development and temperament.Physical wellbeing (including weight, smoking, nutrition and activity level) and any physical health problems.Social factors including:Social networks and quality of interpersonal relationships.Living conditions, employment, economic and immigration status.Domestic violence and abuse, sexual abuse, trauma or childhood maltreatment.Caring for other children and young people or other adults. Alcohol and drug misuse. If alcohol misuse is suspected, use the Alcohol Use Disorders Identification Test (AUDIT) as an identification tool. For more information, see the CKS topic on Alcohol - problem drinking. Assess the severity of depression. For more detailed information, see the section on Assessment in the CKS topic on Depression.Assess the woman's risk of self neglect, self harm or suicide, and any risk to the infant. For more detailed information, see the section on Assessing suicide risk in the CKS topic on Depression.If there is a risk of self harm or suicide, assess whether the woman has adequate social support and is aware of sources of help, arrange help appropriate to the level of risk, and advise the woman, and her partner, family or carer, to seek further help if the situation deteriorates. If there is a risk of, or there are concerns about, suspected child maltreatment, follow local safeguarding protocols. For more information, see the CKS topic on Child maltreatment - recognition and management.In women with depression, exclude differential diagnoses, for example:Ask about periods of abnormally high or irritable mood and increased activity, or a change in their usual energy level that was noticed by others as abnormal, or got them into a troublesome situation. If the response is positive, assess for bipolar disorder.Identify any signs of confusion, abnormal behaviour, delusions, or hallucinations that may indicate the onset of postpartum psychosis.Investigations are not indicated routinely, but may be necessary to exclude other physical causes of symptoms (for example in a woman with predominant fatigue, consider checking her full blood count to exclude anaemia, and thyroid function to exclude hypothyroidism).For more information on the general assessment of a person with depression, see the section on Assessment in the CKS topic on Depression. Back to top Basis for recommendation Basis for recommendation Response to the depression identification questionsScreening tools do not aim to diagnose depression, but do identify which people need further assessment [Jones and Shakespeare, 2014]. The recommendation on the course of action if a woman responds positively to the depression identification questions, is at risk of a mental health problem, or is a cause for clinical concern is based on the National Institute for Health and Care Excellence (NICE) Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. The Edinburgh Postnatal Depression Scale (EPDS) is not as well validated for screening for depression in pregnancy compared with the postnatal period, but based on an evidence review commissioned by NICE, the guideline development group found that the EPDS and Patient Health Questionnaire (PHQ-9) have good sensitivity and specificity and are suitable for assessing women with a positive response to the depression identification questions [National Collaborating Centre for Mental Health, 2014]. Canadian best practice guidelines noted that a positive screen on the EPDS is not the same as a diagnosis of depression [BC Reproductive Mental Health Program, 2014]. The NICE evidence review found the most commonly reported cut-off points for the EPDS are a score of 9/10 for 'possible depression' and 12/13 for 'probable depression', although a higher cut-off of 14/15 in pregnancy was also suggested [National Collaborating Centre for Mental Health, 2014].  Assessment and diagnosis in pregnancy and the postnatal periodThe suggestions on features to identify to assess and diagnose a mental health problem in pregnancy or the postnatal period are a summary of those outlined in the Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014]. In the absence of high-quality evidence, these were based on extrapolation from other NICE guidelines and the expert opinion of the guideline development group and contributors to the guideline development process [National Collaborating Centre for Mental Health, 2014]. CKS has also included information from an international position paper on perinatal mental health [Brockington, 2017] and expert opinion in a clinical practice article on postpartum depression [Stewart and Vigod, 2016].Assessment of severity of depressionThis recommendation is extrapolated from Antenatal and postnatal mental health: clinical management and service guidance, published by NICE, in which treatment recommendations are based on the severity of a woman's depression [NICE, 2014]. CKS, therefore, considers it important to determine severity as part of the assessment process to facilitate appropriate management.Assessment of riskThe recommendation on assessment of risk and what to do if there is a risk of self harm, suicide, or child maltreatment is based on the Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014]. Canadian best practice guidelines on mental health in the perinatal period also emphasise the importance of assessing the risk of suicide and potential risk to the baby [BC Reproductive Mental Health Program, 2014].Exclusion of differential diagnosesThis recommendation is extrapolated from expert opinion in a clinical practice article on postpartum depression which outlines features of other mental health conditions presenting in the perinatal period [Stewart and Vigod, 2016].InvestigationsCKS found no evidence on investigations for depression, but has based this information on what is considered to be good clinical practice. The examples given reflect expert opinion in a clinical practice article on postpartum depression [Stewart and Vigod, 2016].  Back to top Diagnosis How do I confirm the diagnosis of depression? Follow the usual diagnostic criteria for depression (for example ICD-10 and DSM-5). See the section on Diagnosis in the CKS topic on Depression for more detailed information, including the symptoms and signs of depression and the DSM-5 criteria.Bear in mind that diagnosing depression in the perinatal period can be challenging because of normal changes in emotions, responses, mental state, and functioning which may be inappropriately diagnosed as depression or mask depressive symptoms. Features that help to differentiate depression from the normal changes experienced perinatally include:Persistent and marked depressed mood, sadness, irritability, absence of pleasure, difficulty concentrating or making decisions.Hopelessness and overwhelming feelings of responsibility.Feelings of guilt, worthlessness, or being a 'bad' mother.Social withdrawal.Anxiety symptoms (including excessive or unrealistic worry about the baby, difficulty sleeping [even when the baby is], health anxiety, physical symptoms of anxiety).When making a diagnosis of depression in pregnancy or postnatally, also consider information gathered from an assessment of the woman's previous mental and physical health, her pregnancy and/or postnatal experiences, and social circumstances and relationships.  Back to top Basis for recommendation Basis for recommendation Diagnostic criteria for depressionThe recommendation that diagnosis of depression in pregnancy and the postnatal period should follow usual diagnostic guidelines is based on the National Collaborating Centre for Mental Health Antenatal and postnatal mental health: clinical management and service guidance commissioned by the National Institute for Health and Care Excellence (NICE) [National Collaborating Centre for Mental Health, 2014]. This is consistent with the lack of evidence that there is a difference between symptoms of antenatal, postnatal, and non-postnatal depression [SIGN, 2012].  Canadian guidelines suggest that the gold standard for diagnosis is confirmation with the DSM-5 criteria in conjunction with an assessment interview [BC Reproductive Mental Health Program, 2014]. Challenges of diagnosing depression in the perinatal periodCKS has based this recommendation on an evidence review commissioned by NICE [National Collaborating Centre for Mental Health, 2014] and Canadian guidelines [BC Reproductive Mental Health Program, 2014] that discuss the complexities of diagnosing depression in a pregnant or postnatal woman because of the changes occurring at this time. Considering information gathered from an assessment when making a diagnosisThe National Collaborating Centre for Mental Health emphasises the importance of being cautious about diagnosing depression in pregnancy or postnatally without considering the context because some changes in mental state and functioning are a normal part of this time. A careful clinical assessment is needed to identify an underlying mental health problem when a woman is experiencing features such as sleep disturbance, tiredness, and anxious thoughts about the baby [National Collaborating Centre for Mental Health, 2014]. The summary of what an assessment should include is based on Antenatal and postnatal mental health: clinical management and service guidance published by NICE [NICE, 2014] and an international position paper on perinatal mental health [Brockington, 2017]. Back to top Differential diagnosis What else might it be? Baby blues (low mood after childbirth) is a common disorder which is usually mild and short-term, presenting around the second or third postnatal day and resolving by the fifth day. It affects between three and eight women in every ten in the first weeks post-delivery. The baby blues are often considered to be normal emotional changes and responses after childbirth and do not seriously impair functioning.Symptoms include:Insomnia.Fatigue.Tearfulness.Anxiety.Irritability.Impairment of concentration.Mood lability.It is important to distinguish between baby blues and early onset depression, but only a small proportion of women with baby blues will develop postpartum depression.Most women with the baby blues will not require specific treatment other than reassurance.Postpartum psychosis (puerperal psychosis) is an affective psychosis linked to the postnatal period. It is a psychiatric and obstetric emergency, usually requiring hospital treatment.It is rare, affecting one to two in every thousand women.It presents suddenly, usually within 2 weeks post-delivery, and deterioration may be rapid.Symptoms are similar to psychotic symptoms at other times of life and include severe mood swings, delusions, confusion, and hallucinations. Distorted thoughts and behaviour may involve the baby, putting it at risk of harm.Recurrence after subsequent deliveries is common. Bipolar disorder is important to consider as a differential diagnosis if a woman meets the diagnostic criteria for major depression with onset in the perinatal period. It features depression and irritable or elevated mood, but if the predominant mood state is depression it may be misdiagnosed. For more information, see the CKS topic on Bipolar disorder  Other conditions that should be considered include:Generalized anxiety disorder. For more information, see the CKS topic on Generalized anxiety disorder. Obsessive-compulsive disorder. For more information, see the CKS topic on Obsessive-compulsive disorder. Post-traumatic stress disorder. For more information, see the CKS topic on Post-traumatic stress disorder. For more information about the differential diagnosis of depression not specific to the perinatal period, see the section on Differential diagnosis in the CKS topic on Depression. Back to top Basis for recommendation Basis for recommendation Baby blues and postpartum psychosisThe information on baby blues and postpartum psychosis is based on Antenatal and postnatal mental health: clinical management and service guidance from the National Collaborating Centre for Mental Health (commissioned by the National Institute for Health and Care Excellence) [National Collaborating Centre for Mental Health, 2014], the Scottish Intercollegiate Guidelines Network (SIGN) guideline: Management of perinatal mood disorders [SIGN, 2012], a Canadian best practice guideline on mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014], a Cochrane systematic review [Molyneaux et al, 2014], and a clinical practice article on postpartum depression [Stewart and Vigod, 2016].Other conditionsThe information on bipolar disorder and other conditions to consider in the differential diagnosis of depression in pregnancy and the postnatal period is based on a consensus article on perinatal depression and anxiety [Kendig et al, 2017] and expert opinion in review articles [Jones and Shakespeare, 2014; Langan and Goodbred, 2016]. Management Back to topManagement Scenario: Pregnant: on an antidepressant: covers the management of a woman being treated for depression who becomes pregnant.Scenario: Pregnant: new episode: covers the management of a woman with a new episode of depression during the antenatal period.Scenario: Postnatal: new episode: covers the management of a woman with a new episode of depression during the postnatal period. Back to top Scenario: Pregnant: on an antidepressant Scenario: Pregnant woman: on an antidepressant From age 18 years to 60 years (Female). Back to top Making decisions about treatment What issues should I consider when making decisions about treatment? Before discussing the benefits and harms of treatment, or starting, stopping or switching antidepressant treatment during pregnancy, seek advice, ideally from a specialist perinatal mental health team, where available; or from a secondary mental health service; or the UK Teratology Information Service (UKTIS) on 0344 892 0909. Decisions about treating depression during pregnancy should be made on an individual basis. Involve the woman, and her family where appropriate, in all decisions about treatment, taking into account information on:The nature of her depression and severity of symptoms.Any psychiatric and physical comorbidities.Previous history and response to treatment.Stage of pregnancy.The options available and their risk, harms and benefits. The woman's relationships with, and level of support from, family or carers and the needs of her family (for example the welfare of her baby and other children). Discuss: Any particular concerns the woman has about her baby.Her plans regarding breastfeeding. Explain the benefits of breastfeeding and the risks associated with taking psychotropic medication when breastfeeding.The risks or harms to the woman or fetus of stopping antidepressants abruptly or changing treatment. The risks associated with not treating depression during pregnancy.  The risks associated with any pregnancy:Miscarriage or birth defect can occur in any pregnancy even if medication has not been taken.The risk of miscarriage in pregnancy is about 10 to 20 out of every 100 pregnancies.The risk of birth defect is about 1 in 40 pregnancies.The treatment options available to the woman (including psychological treatment, antidepressant treatment, or a combination of psychological and antidepressant treatment), including: The higher threshold for pharmacological interventions arising from the changing risk-benefit ratio for psychotropic medication at this time (also note that no psychotropic medication has a UK marketing authorisation specifically for women who are pregnant or breastfeeding) and the likely benefits of a psychological intervention. The potential benefits of each treatment, considering the severity of the mental health problem.The risks or harms to the woman and the fetus associated with each treatment option. Discuss the uncertainty about whether any increased risk to the fetus and other problems for the woman or baby can be attributed directly to these drugs or may be caused by other factors.Treatment options that would enable a woman to breastfeed if she wishes.The uncertainty about the benefits, risks and harms of treatments for mental health problems in pregnancy.The need for prompt treatment because of the potential effect of an untreated mental health problem on the fetus.For more specific management information, see Managing a woman on treatment who becomes pregnant. Back to top Basis for recommendation Basis for recommendation Seeking specialist adviceThis recommendation is extrapolated from the opinion of the National Institute for Health and Care Excellence (NICE) that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment in pregnancy is needed, or when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, the fact that there are no antidepressants licensed for use during pregnancy (although the use of antidepressants during pregnancy is common) [National Collaborating Centre for Mental Health, 2014] and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].Decision makingThis recommendation is based on the NICE Antenatal and postnatal mental health: clinical management and service guideline [NICE, 2014] and the expert opinion of the NICE guideline development group, which advocated women being actively involved in decisions about their care [National Collaborating Centre for Mental Health, 2014]. The list of information to take into account also includes advice from a British Association for Psychopharmacology consensus guidance [McAllister-Williams et al, 2017] and Canadian best practice guidelines for mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014]. Areas for discussionThis recommendation largely reflects the NICE Antenatal and postnatal mental health: clinical management and service guideline, including the treatment options available to women and specific discussion points associated with them [NICE, 2014]. The National Collaborating Centre for Mental Health states that, for women with depression in pregnancy or the postnatal period, there should be a discussion about treatment options, including benefits and harms, and the potential consequences of abruptly stopping or changing drug treatment [National Collaborating Centre for Mental Health, 2014]. The woman's preferences regarding breastfeeding — women being prescribed an antidepressant in pregnancy are likely to need to continue treatment in the postpartum period as well. Therefore, it seems sensible to consider the woman's desire to breastfeed at this stage, to avoid the need to consider switching antidepressants later [SIGN, 2012].  Risks of abrupt withdrawal of antidepressants — the Scottish Intercollegiate Guidelines Network (SIGN) advises that abrupt discontinuation of antidepressant treatment in women with serious mental illness who are at high risk of relapse is unwise, as relapse may ultimately be more harmful to the mother and child than continued drug treatment [SIGN, 2012]. NICE also emphasises the importance of not stopping medication without professional advice because of the risk of triggering or exacerbating an episode [NICE, 2016]. This is consistent with advice from a British Association for Psychopharmacology consensus guidance which discusses avoidance of suddenly stopping antidepressants on discovering a pregnancy because of the risk of discontinuation syndrome and relapse. Suddenly stopping medication when a woman finds out she is pregnant may not remove the risk of malformations [McAllister-Williams et al, 2017].  Risks of not treating depression — there is some evidence to suggest an increased risk of adverse outcomes for women with severe depression and their babies, including low birthweight, prematurity, sudden infant death syndrome, and self harm [National Collaborating Centre for Mental Health, 2014].  Risks associated with any pregnancy — the information about the background risk of fetal malformations for pregnant women without a mental disorder is based on information from the UK Teratology Information Service [UKTIS, 2013].  Back to top Managing a woman on treatment who becomes pregnant How should I manage a woman being treated for depression who becomes pregnant? Before discussing the benefits and harms of treatment, or starting, stopping or switching antidepressant treatment during pregnancy, seek advice, ideally from a specialist perinatal mental health team, where available; or from a secondary mental health service; or the UK Teratology Information Service (UKTIS) on 0344 892 0909. For more information on prescribing antidepressants and their risks in pregnancy, see Prescribing antidepressants in pregnancy.Advise the woman not to stop taking antidepressants abruptly during pregnancy.If a woman taking a tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI), or a (serotonin-) noradrenaline reuptake inhibitor [(S)NRI] for mild to moderate depression becomes pregnant:Discuss gradually stopping the antidepressant and monitoring the woman. Consider referral for facilitated self-help. If the woman is taking a TCA, SSRI, or (S)NRI for moderate depression and wants to stop her medication, consider her previous response to treatment, stage of pregnancy, preferences for treatment, risk of relapse, and risks of medication and discuss the options of:Switching to a high intensity psychological intervention (for example CBT).Changing medication if there is a drug effective for her with a lower risk of adverse effects.If the woman is taking a TCA, SSRI, or (S)NRI for severe depression, take into account her previous response to treatment, stage of pregnancy, preferences for treatment, risk of relapse, and risks of medication and discuss the options of: Continuing her current medication.Switching to a drug that is effective for her with a lower risk of adverse effects.Using medication in conjunction with a high-intensity psychological intervention (for example CBT).Switching to a high-intensity psychological intervention (for example CBT) if she decides to stop taking medicationIf the woman requires psychological treatment, ensure that she is assessed within 2 weeks of referral and is seen promptly for treatment (ideally, within 1 month of initial assessment). If a woman with depression decides to stop taking psychotropic medication in pregnancy and the postnatal period, monitor her mental status because of the risk of relapse. Discuss with her:Her reasons for stopping.The possibility of other options: for example having a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to other medication.Increasing her monitoring and support while she is not taking any medication.Any risks to herself, or the fetus or baby when stopping medication.Offer written information, for example, the Mind publication Understanding postnatal depression and perinatal mental health, available at www.mind.org.uk. Back to top Basis for recommendation Basis for recommendation The recommendations on management of a woman taking an antidepressant who becomes pregnant are largely based on the National Institute for Health and Care Excellence (NICE) publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014].Seeking specialist advice on antidepressant treatmentThis recommendation is extrapolated from the opinion of NICE that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment in pregnancy is needed, or when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy [National Collaborating Centre for Mental Health, 2014].Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, the fact that there are no antidepressants licensed for use during pregnancy (although the use of antidepressants during pregnancy is common), and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].Abrupt withdrawal of antidepressantsThe Scottish Intercollegiate Guidelines Network (SIGN) advises that abrupt discontinuation of antidepressant treatment in women with serious mental illness who are at high risk of relapse is unwise, as relapse may ultimately be more harmful to the mother and child than continued drug treatment [SIGN, 2012]. NICE also emphasises the importance of not stopping medication without professional advice because of the risk of triggering or exacerbating an episode [NICE, 2016]. This is consistent with advice from a British Association for Psychopharmacology consensus guidance which advises avoidance of suddenly stopping antidepressants on discovering a pregnancy because of the risk of discontinuation syndrome and relapse [McAllister-Williams et al, 2017]. Treating depression in pregnancyThe recommendations to manage pre-existing depression in pregnancy depending on its severity are based mainly on the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Where possible, non-pharmacological management of depression is preferable in pregnancy, particularly in women with mild to moderate symptoms [BC Reproductive Mental Health Program, 2014; UKTIS, 2017]. NICE recommends discussing stopping antidepressants gradually in women with mild to moderate depression who become pregnant [NICE, 2014]. However relapse rates are high in people with a history of depression who discontinue their treatment, and not treating depression in pregnancy may be associated with adverse outcomes for the woman, her pregnancy, and her infant [SIGN, 2012]. Efficacy of non-pharmacological treatment in pregnancy and the postnatal periodThere are few studies of the efficacy of psychological treatments in pregnant women. Given that the nature of most mental health problems during pregnancy is similar to that in non-pregnant women, it seems reasonable to assume that these psychological treatments are also likely to be effective in pregnant women [National Collaborating Centre for Mental Health, 2014]. When making its recommendations for women with varying severities of depression in pregnancy and the postnatal period, the NICE guideline development group (GDG) considered the evidence for the clinical and cost-effectiveness of facilitated self help and structured psychological interventions for the treatment of depression in non-pregnant women and also took into account the findings of an evidence review [National Collaborating Centre for Mental Health, 2014]:  Up to three studies (n = 1136) showed moderate clinical benefits of facilitated self help on the symptoms of depression compared with usual treatment in women with subthreshold to moderate symptoms of depression in pregnancy or the postnatal period (very low to high quality evidence).Up to ten studies showed large to moderate benefits with structured psychological interventions (CBT or IPT) in terms of depression diagnosis and symptoms (very low to high quality evidence), in addition to continued moderate to large effects in the short and intermediate term (low quality evidence).One study showed a large effect of structured psychological interventions on anxiety symptoms in women with depression (low quality evidence).For persistent subthreshold depressive symptoms, or mild to moderate depression, the GDG recommended considering facilitated self help and that its delivery should include written materials, support by a trained practitioner face-to-face or by telephone, and take place in usually six to eight sessions over a nine to twelve week period [National Collaborating Centre for Mental Health, 2014]. For moderate to severe depression in pregnancy or the postnatal period, the GDG advised offering options in line with existing NICE guidance (taking into account the higher threshold for pharmcological treatment in pregnancy or breastfeeding), including structured psychological interventions (CBT or IPT) [National Collaborating Centre for Mental Health, 2014]. Efficacy of pharmacological treatments in pregnancy and the postnatal periodThere is good evidence of efficacy for pharmacological treatments for depression in the general population (see the NICE guideline Depression: the treatment and management of depression in adults [NICE, 2009] for more information). Because of ethical considerations, there are few data regarding the efficacy of antidepressants in pregnant women [Taylor et al, 2012]; however, pharmacological treatments are not thought to have any differential benefit in pregnancy or the postnatal period compared with their use in other adult populations. The main difference at this time is the risk-benefit ratio [National Collaborating Centre for Mental Health, 2014]. An evidence review on the efficacy of pharmacological interventions for mental health problems in pregnancy and the postnatal period commissioned by NICE found [National Collaborating Centre for Mental Health, 2014]: One small study (n = 31) showing a moderate beneficial effect of mean depression scores when paroxetine was compared with placebo (very low quality evidence).Another study (n = 83) that found SSRIs had no statistically significant benefit compared with TCAs in terms of mean depression scores either post-treatment or at intermediate follow up (low quality evidence).Three studies (n = 188) indicating SSRIs combined with psychosocial interventions had a moderately beneficial effect on mean depression scores post intervention compared with placebo plus psychological interventions (low quality evidence).One study (n = 254) showing a moderate beneficial effect of antidepressants compared with general supportive care in terms of symptoms of depression post-treatment (very low quality evidence).Prompt treatment for women requiring psychological treatmentThe recommendation that psychological interventions for a pregnant or postnatal woman with a mental health problem should be provided within 1 month of initial assessment is based on Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014]. The Royal College of Psychiatrists also note that psychological therapy services (including Improving Access to Psychological Therapies [IAPT]) should ensure prompt assessment and treatment of perinatal women [Royal College of Psychiatrists, 2015].  Reasons for the need for prompt intervention include [National Collaborating Centre for Mental Health, 2014; NICE, 2016]: The potential impact of the woman's depression on the fetus or baby and her ability to function and care for herself and others in her family.Prioritisation of psychological interventions because of the higher threshold for drug treatments in pregnancy, taking into account the altered risk-benefit ratio at this time. However, it is acknowledged that access to psychological treatments may be limited, creating challenges for perinatal services [National Collaborating Centre for Mental Health, 2014]. Stopping psychotropic medication in pregnancy and the postnatal periodThis recommendation is based on Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014] and Canadian best practice guidelines on mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014]. Offering written informationCKS has based this recommendation on the NICE recommendation to provide culturally relevant information on mental health problems in pregnancy and the postnatal period to the woman [NICE, 2014].  Back to top Referral and specialist advice When should I refer or seek specialist advice? Urgently refer to a secondary mental health team (ideally with a special interest in perinatal mental health) if a woman:Is severely depressed and presents a considerable immediate risk of harm to herself or other people — admission may be required if clinically indicated. Shows evidence of severe self-neglect or is unable to care for her infant.Has a possible diagnosis of bipolar disorder. For more information, see the CKS topic on Bipolar disorder.Has a history of severe mental illness, including postnatal depression, puerperal psychosis, or bipolar disorder (during pregnancy or the postnatal period or at any other time). Refer to a specialist substance misuse service if, in addition to depression, the woman has harmful or dependent drug or alcohol misuse in pregnancy or the postnatal period.Refer or seek specialist advice if:Considering continuing, starting, stopping, or switching antidepressant treatment during pregnancy.Considering reducing the dose of, or discontinuing, antidepressant treatment close to delivery.The woman is not responding to treatment appropriate to the severity of her depression.Specialist advice may be sought ideally from a specialist perinatal mental health team where available, or from a secondary mental health service or the UK Teratology Information Service (UKTIS) on 0844 892 0909.Other factors to be taken into account when deciding whether to refer or seek specialist advice include:The woman's preference.The woman's past history and response to treatment.The degree of functional impairment.The presence of significant comorbidities or specific symptoms. Back to top Basis for recommendation Basis for recommendation Urgent referral These recommendations reflect referral advice in the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Recommendations have also been extrapolated from the NICE guidance Depression in adults: recognition and management [NICE, 2009] (although this is not specifically aimed at women in the antenatal or postnatal period). CKS has recommended the same diagnostic criteria for depression in the antenatal and postnatal periods, based on advice from the National Collaborating Centre for Mental Health to use usual diagnostic guidelines [National Collaborating Centre for Mental Health, 2014]. It would seem reasonable therefore to extrapolate referral advice to cover women who are depressed either antenatally or postnatally.Urgent referral criteria also reflect expert opinion in clinical practice articles [Langan and Goodbred, 2016; Stewart and Vigod, 2016].  Referral to a specialist substance misuse serviceThis recommendation is based on the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Referral or seeking advice on treatment decisionsThis recommendation on antidepressant treatment during pregnancy is extrapolated from the opinion of NICE that advises considering seeking advice, preferably from a specialist perinatal mental health service, when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014]. Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks, and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy or the postnatal period [National Collaborating Centre for Mental Health, 2014].There is a lack of evidence or expert consensus regarding whether the risk of poor neonatal adaptation will be influenced by reducing or stopping antidepressant treatment close to delivery and it may increase the woman's risk of relapse and postnatal depression [McAllister-Williams et al, 2017]. NICE recommends treating depression according to the severity of the episode [NICE, 2014]. If the treatment recommended by NICE for the severity of the woman's depression is not controlling symptoms, CKS recommends seeking specialist advice. Factors influencing the decision to referNICE advocates discussion with the woman about the risks and benefits of interventions, and her values and preferences in order for her to reach a fully informed decision and suggests also involving (with the woman's agreement) her partner, family or carer, in decision making [NICE, 2014]. Other factors are based on what CKS considers to be good clinical practice.  Back to top Prescribing antidepressants in pregnancy What should I consider before prescribing an antidepressant in pregnancy? Before discussing the benefits and harms of treatment, or starting, stopping or switching antidepressant treatment during pregnancy, seek advice, ideally from a specialist perinatal mental health team, where available; or from a secondary mental health service; or the UK Teratology Information Service (UKTIS) on 0344 892 0909. If an antidepressant is required in pregnancy: The threshold for antidepressant prescribing should be adjusted compared with nonpregnant women because of the uncertain risks in pregnancy, and increased monitoring and support offered.The choice of drug should be based on the woman's previous response to medication, the stage of pregnancy, and the risk profile for her and her fetus or baby.Note that no psychotropic medication has a UK marketing authorisation specifically for women who are pregnant or breastfeeding and informed consent should be obtained and documented.The lowest effective dose should be prescribed, but ensure that depression is adequately treated. Be aware that dosages may need adjustment during pregnancy.The risk of discontinuation symptoms in the woman and neonatal adaptation syndrome in the baby with most tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs], in particular paroxetine and venlafaxine, should be taken into account.A single drug should be used, if possible, rather than two or more drugs.Risks of selective serotonin reuptake inhibitors (SSRIs):In terms of malformation risk, a definite association between SSRI use in pregnancy and the occurrence of fetal malformation has not been confirmed.Data for SSRIs as a class are conflicting and confounded. There is an indication from some studies that there may be a small increase in the absolute risk of cardiovascular malformations when a fetus is exposed to an SSRI during pregnancy, but other studies did not support this and meta-analyses did not confirm the association. There is a suggestion that confounding factors affecting women with the conditions for which SSRIs are indicated may account for the increased cardiac malformation rates in some studies. Other specific congenital malformations have been reported with SSRI use as a class in some studies, but these results have not been reproduced.Some studies show an association between SSRI use in pregnancy and an increased risk of spontaneous abortion (odds ratio about 1.5), low birth weight, and preterm delivery, but data are conflicting and it is unclear how common these outcomes are. It is also possible that maternal depression may be a confounding factor as these outcomes have all been associated with this condition.Persistent pulmonary hypertension has been found to be more likely to affect newborns exposed to SSRIs after 20 weeks of gestation compared with the general population, although the absolute risk is low (0.2–1.2% with SSRI exposure compared with 0.1–0.2%).There are conflicting data on neurodevelopmental impairment after maternal SSRI use in pregnancy and there were methodological limitations to some of the studies therefore more information is needed. Autism spectrum disorder has been associated with SSRI use in pregnancy, but this may also be associated with the mother's underlying condition and more evidence is needed. Transient neonatal withdrawal syndrome can affect infants exposed to SSRIs in the weeks leading up to delivery and can cause central nervous system, motor, respiratory, and gastrointestinal symptoms.Serotonin-blocking antidepressants may increase the risk of postpartum haemorrhage, but the size and significance of this risk is not clear.Risks of tricyclic antidepressants (TCAs)Data does not show strong evidence that TCAs as a class are associated with an overall increased risk of congenital malformations, howev,er information is limited on specific TCAs, meaning an increased risk of malformations cannot be completely excluded. Cardiac malformations may be associated with exposure to clomipramine, but this has not been confirmed. Although data is conflicting, there is a possible association with TCA use in pregnancy and preeclampsia, spontaneous abortion, preterm delivery and autism spectrum disorder.Neonatal withdrawal symptoms and/or poor neonatal adaptation syndrome may also be associated with TCA use throughout pregnancy or close to delivery.Risks of (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs], for example, duloxetine and venlafaxine: There are very limited data available on the use of duloxetine in pregnancy, therefore, its use would not be routinely recommended. If venlafaxine use is being considered in pregnancy UKTIS recommend the case is discussed with them and the woman carefully counselled. (S)NRIs share similar properties with SSRIs which are associated with an increased risk of persistent pulmonary hypertension of the newborn. Neonatal problems observed in infants exposed to (S)NRIs in utero are similar to those reported with SSRIs and include irritabilty, tremor, muscle weakness, difficulty sucking, respiratory problems, low apgar score, hypoglycaemia, and convulsions. The neonate should be monitored for adverse effects post-delivery. For information regarding the risks of using specific antidepressant drugs in pregnancy, see the individual monographs available from the UK Teratology Information Service at www.uktis.org. Detailed summaries of the risks associated with these drugs are available on the Toxbase website www.toxbase.org; access to the the website is free to health care professionals; however, registration is required.  Back to top Basis for recommendation Basis for recommendation Seeking specialist adviceThis recommendation is extrapolated from the opinion of the National Institute for Health and Care Excellence (NICE) that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment in pregnancy is needed, or when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014]. Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, the fact that there are no antidepressants licensed for use during pregnancy (although the use of antidepressants during pregnancy is common) [National Collaborating Centre for Mental Health, 2014] and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].NICE advises that when choosing an antidepressant, prescribers should be aware that their safety in pregnancy and breastfeeding is not well understood [National Collaborating Centre for Mental Health, 2014] Choice of drug and prescribing advice in pregnancyThis recommendation is based on the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014; National Collaborating Centre for Mental Health, 2014]. An evidence review commissioned by NICE outlined the complexities of making decisions about psychotropic medicine use during pregnancy and in breastfeeding on an individual basis, taking into account the woman's stage of pregnancy and, in particular, the risk of severe episodes of mental illness in relation to childbirth, the consequences for her family, the reproductive safety of medication and background risks of malformation, and the risk of neonatal withdrawal [National Collaborating Centre for Mental Health, 2014]. The advice to prescribe the lowest effective dose also reflects Canadian best practice guidelines [BC Reproductive Mental Health Program, 2014] and the opinion of the UK Teratology Information Service (UKTIS) [UKTIS, 2017].  A British Association for Psychopharmacology consensus guideline advises generally avoiding switching medication in pregnancy unless the benefit outweighs the risks, and that the most important information about the efficacy of a drug for a particular woman is based on her own treatment history. If a woman has previously had a good response to a medication, there should be a good reason not to recommend it or to use a drug with unknown efficacy, even if it has a lower risk in pregnancy [McAllister-Williams et al, 2017].Risks of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs) and (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs]This information is largely based on a review of the available data by the UKTIS on the use of SSRIs, TCAs and (S)NRIs (duloxetine and venlafaxine) during pregnancy [UKTIS, 2016; UKTIS, 2017; UKTIS, 2018a; UKTIS, 2018b].UKTIS is recommended as a good source of information on specific drug use in pregnancy by a systematic review of recognition and management of perinatal depression and anxiety by general practitioners [Ford et al, 2017]. Information is also consistent with discussion of risks of SSRI and (S)NRI use in pregnancy in British Association for Psychopharmocology consensus guidance [McAllister-Williams et al, 2017], Canadian consensus guidelines [MacQueen et al, 2016], Medicines and Healthcare products Regulatory Agency guidance [MHRA, 2014], and meta-analyses of cohort and case-control studies [Mezzacappa et al, 2017; Zhang et al, 2017]. Back to top Follow up How should I follow-up a pregnant woman with depression? When following up a woman with depression in the antenatal or postnatal periods:Assess and agree the level of contact and support needed. Regularly monitor for symptoms during pregnancy and the postnatal period, particularly in the first few weeks after childbirth. At all contacts, consider asking the two depression identification questions as part of a general discussion about her mental health and wellbeing and using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of monitoring.At each postnatal contact, ask about the woman's emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Encourage women and their families/partners to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern. Discuss how her symptoms will be monitored, for example by using validated self-report questionnaires, such as the EPDS or PHQ-9. If a woman is on drug treatment, review frequently, with dose adjustment if necessary.Encourage postnatal women to help look after their mental health by looking after themselves, for example, taking gentle exercise, resting, seeking help with caring for the baby, and talking to someone about how they are feeling.  Back to top Basis for recommendation Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence (NICE) publications Antenatal and postnatal mental health (clinical management and service guidance) [NICE, 2014] and Postnatal care up to 8 weeks after birth [NICE, 2006a]. The recommendation about frequent review of drug treatment is based on a consensus article on perinatal depression and anxiety [Kendig et al, 2017]. The recommendations are also supported by an evidence review commissioned by NICE which discussed that monitoring of the effects of interventions should be a continual process and incorporated into routine care, where possible [National Collaborating Centre for Mental Health, 2014].  Back to top Scenario: Pregnant: new episode Scenario: Pregnant woman: new episode From age 18 years to 60 years (Female). Back to top Making decisions about treatment What issues should I consider when making decisions about treatment? Before discussing the benefits and harms of treatment, or starting, stopping, or switching antidepressant treatment during pregnancy, seek advice, ideally from a specialist perinatal mental health team, where available; or from a secondary mental health service; or the UK Teratology Information Service (UKTIS) on 0344 892 0909. Decisions about treating depression during pregnancy should be made on an individual basis. Involve the woman, and her family where appropriate, in all decisions about treatment, taking into account information on:The nature of her depression and severity of symptoms.Any psychiatric and physical comorbidities.Previous history and response to treatment.Stage of pregnancy.The options available and their risk, harms and benefits. The woman's relationships with, and level of support from, family or carers and the needs of her family (for example the welfare of her baby and other children). Discuss: Any particular concerns the woman has about her baby.Her plans regarding breastfeeding. Explain the benefits of breastfeeding and the risks associated with taking psychotropic medication when breastfeeding.The risks or harms to the woman or fetus of stopping antidepressants abruptly or changing treatment. The risks associated with not treating depression during pregnancy.  The risks associated with any pregnancy:Miscarriage or birth defect can occur in any pregnancy even if medication has not been taken.The risk of miscarriage in pregnancy is about 10 to 20 out of every 100 pregnancies.The risk of birth defect is about 1 in 40 pregnancies.The treatment options available to the woman (including psychological treatment, antidepressant treatment, or a combination of psychological and antidepressant treatment), including: The higher threshold for pharmacological interventions arising from the changing risk-benefit ratio for psychotropic medication at this time (also note that no psychotropic medication has a UK marketing authorisation specifically for women who are pregnant or breastfeeding) and the likely benefits of a psychological intervention. The potential benefits of each treatment, considering the severity of the mental health problem.The risks or harms to the woman and the fetus associated with each treatment option. Discuss the uncertainty about whether any increased risk to the fetus and other problems for the woman or baby can be attributed directly to these drugs or may be caused by other factors.Treatment options that would enable a woman to breastfeed if she wishes.The uncertainty about the benefits, risks and harms of treatments for mental health problems in pregnancy.The need for prompt treatment because of the potential effect of an untreated mental health problem on the fetus.For more specific management information, see Managing a new episode in pregnancy.  Back to top Basis for recommendation Basis for recommendation Seeking specialist adviceThis recommendation is extrapolated from the opinion of the National Institute for Health and Care Excellence (NICE) that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment in pregnancy is needed, or when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, the fact that there are no antidepressants licensed for use during pregnancy (although the use of antidepressants during pregnancy is common) [National Collaborating Centre for Mental Health, 2014], and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy or the postnatal period [National Collaborating Centre for Mental Health, 2014].Decision makingThis recommendation is based on the NICE Antenatal and postnatal mental health: clinical management and service guideline [NICE, 2014] and the expert opinion of the NICE guideline development group, which advocated women being actively involved in decisions about their care [National Collaborating Centre for Mental Health, 2014]. The list of information to take into account also includes advice from a British Association for Psychopharmacology consensus guidance [McAllister-Williams et al, 2017] and Canadian best practice guidelines for mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014]. Areas for discussionThis recommendation largely reflects the NICE Antenatal and postnatal mental health: clinical management and service guideline, including the treatment options available to women and specific discussion points associated with them [NICE, 2014]. The National Collaborating Centre for Mental Health states that, for women with depression in pregnancy or the postnatal period, there should be a discussion about treatment options, including benefits and harms, and the potential consequences of abruptly stopping or changing drug treatment [National Collaborating Centre for Mental Health, 2014]. The woman's preferences regarding breastfeeding — women being prescribed an antidepressant in pregnancy are likely to need to continue treatment in the postpartum period as well, therefore, it seems sensible to consider the woman's desire to breastfeed at this stage, to avoid the need to consider switching antidepressants later [SIGN, 2012].Risks of abrupt withdrawal of antidepressants — the Scottish Intercollegiate Guidelines Network (SIGN) advises that abrupt discontinuation of antidepressant treatment in women with serious mental illness who are at high risk of relapse is unwise, as relapse may ultimately be more harmful to the mother and child than continued drug treatment [SIGN, 2012]. NICE also emphasises the importance of not stopping medication without professional advice because of the risk of triggering or exacerbating an episode [NICE, 2016]. This is consistent with advice from a British Association for Psychopharmacology consensus guidance which discusses avoidance of suddenly stopping antidepressants on discovering a pregnancy because of the risk of discontinuation syndrome and relapse. Suddenly stopping medication when a woman finds out she is pregnant may not remove the risk of malformations [McAllister-Williams et al, 2017]. Risks of not treating depression — there is some evidence to suggest an increased risk of adverse outcomes for women with severe depression and their babies, including low birthweight, prematurity, sudden infant death syndrome, and self harm [National Collaborating Centre for Mental Health, 2014].  Risks associated with any pregnancy — the information about the background risk of fetal malformations for pregnant women without a mental disorder is based on information from the UK Teratology Information Service [UKTIS, 2013]. Back to top Managing a new episode in pregnancy How should I manage a new episode of depression in a woman who is pregnant? Before discussing the benefits and harms of treatment or starting, stopping, or switching antidepressant treatment in pregnancy, seek advice, ideally from a specialist perinatal mental health team, where available; or from secondary psychiatric care, or the UK Teratology Information Service (UKTIS) on 0344 892 0909. For more information on prescribing antidepressants and their risks in pregnancy, see Prescribing antidepressants in pregnancy. For a woman with persistent subthreshold depressive symptoms, or mild to moderate depression in pregnancy, consider referral for facilitated self-help.For a woman with a history of severe depression who initially presents with mild depression in pregnancy consider a tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI), or a (serotonin-) noradrenaline reuptake inhibitor [(S)NRI].For a woman with moderate or severe depression in pregnancy, consider the following options:Referral for a high-intensity psychological intervention (for example, CBT).A TCA, SSRI or (S)NRI if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and:She has expressed a preference for medication, orShe declines psychological interventions, orHer symptoms have not responded to psychological interventionsReferral for a high-intensity psychological intervention in combination with medication if the woman understands the risks associated with the medication and the mental health problem in pregnancy and the postnatal period and there is no response, or a limited response, to a high-intensity psychological intervention or medication alone.If the woman requires psychological treatment, ensure that she is assessed within 2 weeks of referral and is seen promptly for treatment (ideally, within 1 month of initial assessment).If a woman with depression decides to stop taking psychotropic medication in pregnancy, monitor her mental status because of the risk of relapse. Discuss with her:Her reasons for stopping.The possibility of other options: for example having a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to other medication.Increasing her monitoring and support while she is not taking any medication.Any risks to herself, or the fetus or baby when stopping medication. Offer written information, for example, the Mind publication Understanding postnatal depression and perinatal mental health, available at www.mind.org.uk. Back to top Basis for recommendation Basis for recommendation The recommendations on management of a woman experiencing a new epsiode of depression in pregnancy are largely based on the National Institute for Health and Care Excellence (NICE) publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014].Seeking specialist advice on antidepressant treatmentThis recommendation is extrapolated from the opinion of NICE that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment in pregnancy is needed, or when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, the fact that there are no antidepressants licensed for use during pregnancy (although the use of antidepressants during pregnancy is common) [National Collaborating Centre for Mental Health, 2014] and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014]. Treating depression in pregnancyThe recommendations to treat depression in pregnancy depending on its severity are based mainly on the National Institute for Health and Care Excellence (NICE) publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Not treating depression in pregnancy may be associated with adverse outcomes for the woman, her pregnancy, and the infant. The treatment with the lowest known risk should be chosen [SIGN, 2012].Where possible, non-pharmacological management of depression is preferable in pregnancy, particularly in women with mild to moderate symptoms [BC Reproductive Mental Health Program, 2014; UKTIS, 2017].Efficacy of non-pharmacological treatment in pregnancy and the postnatal periodThere are few studies of the efficacy of psychological treatments in pregnant women. Given that the nature of most mental health problems during pregnancy is similar to that in non-pregnant women, it seems reasonable to assume that these psychological treatments are also likely to be effective in pregnant women [National Collaborating Centre for Mental Health, 2014]. When making its recommendations for women with varying severities of depression in pregnancy and the postnatal period, the NICE guideline development group (GDG) considered the evidence for the clinical and cost-effectiveness of facilitated self help and structured psychological interventions for the treatment of depression in non-pregnant women and also took into account the findings of an evidence review [National Collaborating Centre for Mental Health, 2014]:   Up to three studies (n = 1136) showed moderate clinical benefits of facilitated self help on the symptoms of depression compared with usual treatment in women with subthreshold to moderate symptoms of depression in pregnancy or the postnatal period (very low to high quality evidence).Up to ten studies showed large to moderate benefits with structured psychological interventions (CBT or IPT) in terms of depression diagnosis and symptoms (very low to high quality evidence), in addition to continued moderate to large effects in the short and intermediate term (low quality evidence).One study showed a large effect of structured psychological interventions on anxiety symptoms in women with depression (low quality evidence).For persistent subthreshold depressive symptoms, or mild to moderate depression, the GDG recommended considering facilitated self help and that its delivery should include written materials, support by a trained practitioner face-to-face or by telephone, and take place in usually six to eight sessions over a nine to twelve week period [National Collaborating Centre for Mental Health, 2014]. For moderate to severe depression in pregnancy or the postnatal period, the GDG advised offering options in line with existing NICE guidance (taking into account the higher threshold for pharmcological treatment in pregnancy or breastfeeding), including structured psychological interventions (CBT or IPT) [National Collaborating Centre for Mental Health, 2014]. Efficacy of pharmacological treatments in pregnancy and the postnatal periodThere is good evidence of efficacy for pharmacological treatments for depression in the general population (see the NICE guideline Depression: the treatment and management of depression in adults [NICE, 2009] for more information). Because of ethical considerations, there are few data regarding the efficacy of antidepressants in pregnant women [Taylor et al, 2012]; however, pharmacological treatments are not thought to have any differential benefit in pregnancy or the postnatal period compared with their use in other adult populations. The main difference at this time is the risk-benefit ratio [National Collaborating Centre for Mental Health, 2014]. An evidence review on the efficacy of pharmacological interventions for mental health problems in pregnancy and the postnatal period commissioned by NICE found [National Collaborating Centre for Mental Health, 2014]:  One small study (n = 31) showing a moderate beneficial effect of mean depression scores when paroxetine was compared with placebo (very low quality evidence).Another study (n = 83) that found SSRIs had no statistically significant benefit compared with TCAs in terms of mean depression scores either post-treatment or at intermediate follow up (low quality evidence).Three studies (n = 188) indicating SSRIs combined with psychosocial interventions had a moderately beneficial effect on mean depression scores post intervention compared with placebo plus psychological interventions (low quality evidence).One study (n = 254) showing a moderate beneficial effect of antidepressants compared with general supportive care in terms of symptoms of depression (very low quality evidence).Prompt treatment for women requiring psychological treatmentThe recommendation that psychological interventions for a woman with a mental health problem should be provided within 1 month of initial assessment is based on Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014]. The Royal College of Psychiatrists also notes that psychological therapy services (including Improving Access to Psychological Therapies [IAPT]) should ensure prompt assessment and treatment of perinatal women [Royal College of Psychiatrists, 2015].  Reasons for the need for prompt intervention include [National Collaborating Centre for Mental Health, 2014; NICE, 2016]:  The potential impact of the woman's depression on the fetus or baby and her ability to function and care for herself and others in her family.Prioritisation of psychological interventions because of the higher threshold for drug treatments in pregnancy, taking into account the altered risk-benefit ratio at this time. However, it is acknowledged that access to psychological treatments may be limited, creating challenges for perinatal services [National Collaborating Centre for Mental Health, 2014]. Stopping psychotropic medication in pregnancy and the postnatal periodThis recommendation is based on Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014] and Canadian best practice guidelines on mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014].  Offering written informationCKS has based this recommendation on the NICE recommendation to provide culturally relevant information on mental health problems in pregnancy and the postnatal period to the woman [NICE, 2014].   Back to top Referral and specialist advice When should I refer or seek specialist advice? Urgently refer to a secondary mental health team (ideally with a special interest in perinatal mental health) if a woman:Is severely depressed and presents a considerable immediate risk of harm to herself or other people — admission may be required if clinically indicated.Shows evidence of severe self-neglect or is unable to care for her infant. Has a possible diagnosis of bipolar disorder. For more information, see the CKS topic on Bipolar disorder. Has a history of severe mental illness, including postnatal depression, puerperal psychosis, or bipolar disorder (during pregnancy or the postnatal period or at any other time). Refer to a specialist substance misuse service if, in addition to depression, the woman has harmful or dependent drug or alcohol misuse in pregnancy or the postnatal period. Refer or seek specialist advice if:Considering continuing, starting, stopping, or switching antidepressant treatment during pregnancy.Considering reducing the dose of, or discontinuing, antidepressant treatment close to delivery.The woman is not responding to treatment appropriate to the severity of her depression.Specialist advice may be sought ideally from a specialist perinatal mental health team where available, or from a secondary mental health service or the UK Teratology Information Service (UKTIS) on 0844 892 0909.Other factors to be taken into account when deciding whether to refer include:The woman's preference.The woman's past history and response to treatment.The degree of functional impairment.The presence of significant comorbidities or specific symptoms. Back to top Basis for recommendation Basis for recommendation Urgent referral These recommendations reflect referral advice in the National Institute for Health and Care Excellence (NICE) publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Recommendations have also been extrapolated from the NICE guidance Depression in adults: recognition and management [NICE, 2009] (although this is not specifically aimed at women in the antenatal or postnatal period). CKS has recommended the same diagnostic criteria for depression in the antenatal and postnatal periods, based on advice from the National Collaborating Centre for Mental Health to use usual diagnostic guidelines [National Collaborating Centre for Mental Health, 2014]. It would seem reasonable therefore to extrapolate referral advice to cover women who are depressed either antenatally or postnatally. The referral criteria also reflect expert opinion in clinical practice articles [Langan and Goodbred, 2016; Stewart and Vigod, 2016].  Referral to a specialist substance misuse serviceThis recommendation is based on the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Referral or seeking advice on treatment decisionsThis recommendation on antidepressant treatment during pregnancy is extrapolated from the opinion of NICE, that advises considering seeking advice, preferably from a specialist perinatal mental health service, when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014]. Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy or the postnatal period [National Collaborating Centre for Mental Health, 2014].There is a lack of evidence or expert consensus regarding whether the risk of poor neonatal adaptation will be influenced by reducing or stopping antidepressant treatment close to delivery and it may increase the woman's risk of relapse and postnatal depression [McAllister-Williams et al, 2017]. NICE recommends treating depression according to the severity of the episode [NICE, 2014]. If the treatment recommended by NICE for the severity of the woman's depression is not controlling symptoms, CKS recommends seeking specialist advice.Factors influencing the decision to referNICE advocates discussion with the woman about the risks and benefits of interventions, and her values and preferences in order for her to reach a fully informed decision and suggests also involving (with the woman's agreement) her partner, family or carer, in decision making [NICE, 2014]. Other factors are based on what CKS considers to be good clinical practice. Back to top Prescribing antidepressants in pregnancy What should I consider before prescribing an antidepressant in pregnancy? Before discussing the benefits and harms of treatment or starting, stopping, or switching antidepressant treatment during pregnancy, seek advice, ideally from a specialist perinatal mental health team, where available; or from secondary psychiatric care or the UK Teratology Information Service (UKTIS) on 0844 892 0909. If choosing a selective serotonin reuptake inhibitor (SSRI), tricyclic antidepressant (TCA), or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI] in pregnancy:  The threshold for antidepressant prescribing should be adjusted compared with nonpregnant women because of the uncertain risks in pregnancy, and increased monitoring and support offered.The choice of drug should be based on the woman's previous response to medication, the stage of pregnancy, and the risk profile for her and her fetus or baby. Note that no psychotropic medication has a UK marketing authorisation specifically for women who are pregnant or breastfeeding and informed consent should be obtained and documented.The lowest effective dose should be prescribed, but ensure that depression is adequately treated. Be aware that dosages may need adjustment during pregnancy.The risk of discontinuation symptoms in the woman and neonatal adaptation syndrome in the baby with most TCAs, SSRIs and (S)NRIs, in particular, paroxetine and venlafaxine, should be taken into account.A single drug should be used, if possible, rather than two or more drugs.Risks of selective serotonin reuptake inhibitors (SSRIs):In terms of malformation risk, a definite association between SSRI use in pregnancy and the occurrence of fetal malformation has not been confirmed.Data for SSRIs as a class are conflicting and confounded. There is an indication from some studies that there may be a small increase in the absolute risk of cardiovascular malformations when a fetus is exposed to an SSRI during pregnancy, but other studies did not support this and meta-analyses did not confirm the association. There is a suggestion that confounding factors affecting women with the conditions for which SSRIs are indicated may account for the increased cardiac malformation rates in some studies. Other specific congenital malformations have been reported with SSRI use as a class in some studies, but these results have not been reproduced.Some studies show an association between SSRI use in pregnancy and an increased risk of spontaneous abortion (odds ratio about 1.5), low birth weight, and preterm delivery, but data are conflicting and it is unclear how common these outcomes are. It is also possible that maternal depression may be a confounding factor as these outcomes have all been associated with this condition.Persistent pulmonary hypertension has been found to be more likely to affect newborns exposed to SSRIs after 20 weeks of gestation compared with the general population, although the absolute risk is low (0.2–1.2% with SSRI exposure compared with 0.1–0.2%).There are conflicting data on neurodevelopmental impairment after maternal SSRI use in pregnancy and there were methodological limitations to some of the studies, therefore, more information is needed. Autism spectrum disorder has been associated with SSRI use in pregnancy, but this may also be associated with the mother's underlying condition and more evidence is needed. Transient neonatal withdrawal syndrome can affect infants exposed to SSRIs in the weeks leading up to delivery and can cause central nervous system, motor, respiratory, and gastrointestinal symptoms.Serotonin-blocking antidepressants may increase the risk of postpartum haemorrhage, but the size and significance of this risk are not clear.Risks of tricyclic antidepressants (TCAs)Data do not show strong evidence that TCAs as a class are associated with an overall increased risk of congenital malformations, however, information is limited on specific TCAs, meaning an increased risk of malformations cannot be completely excluded. Cardiac malformations may be associated with exposure to clomipramine, but this has not been confirmed. Although data are conflicting, there is a possible association with TCA use in pregnancy and preeclampsia, spontaneous abortion, preterm delivery and autism spectrum disorder.Neonatal withdrawal symptoms and/or poor neonatal adaptation syndrome may also be associated with TCA use throughout pregnancy or close to delivery.Risks of (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs], for example, duloxetine and venlafaxine: There are very limited data available on the use of duloxetine in pregnancy, therefore, its use would not be routinely recommended. If venlafaxine use is being considered in pregnancy UKTIS recommend the case is discussed with them and the woman carefully counselled.(S)NRIs share similar properties with SSRIs which are associated with an increased risk of persistent pulmonary hypertension of the newborn (PPHN). Neonatal problems observed in infants exposed to (S)NRIs in utero are similar to those reported with SSRIs and include irritability, tremor, muscle weakness, difficulty sucking, respiratory problems, low apgar score, hypoglycaemia, and convulsions. The neonate should be monitored for adverse effects post-delivery. For information regarding the risks of using specific drugs in pregnancy, see the individual monographs available from the UK Teratology Information Service at www.uktis.org. Detailed summaries of the risks associated with these drugs are available on the Toxbase website www.toxbase.org; access to the website is free to health care professionals; however, registration is required.  Back to top Basis for recommendation Basis for recommendation Seeking specialist adviceThis recommendation is extrapolated from the opinion of the National Institute for Health and Care Excellence (NICE) that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment in pregnancy is needed, or when psychotropic medication is started in pregnancy [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].Seeking specialist advice is also recommended due to the uncertainty regarding the benefits, risks and potential harms of mental health treatments in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014], the fact that the UK Teratology Information Service (UKTIS) does not make specific recommendations on the 'safest' antidepressants in pregnancy, the fact that there are no antidepressants licensed for use during pregnancy (although the use of antidepressants during pregnancy is common) [National Collaborating Centre for Mental Health, 2014] and the opinion of the NICE guideline development group that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy or the postnatal period [National Collaborating Centre for Mental Health, 2014].NICE advises that when choosing an antidepressant, prescribers should be aware that their safety in pregnancy and breastfeeding is not well understood [National Collaborating Centre for Mental Health, 2014]. Choice of drug and prescribing advice in pregnancyThis recommendation is based on the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014; National Collaborating Centre for Mental Health, 2014]. An evidence review commissioned by NICE outlined the complexities of making decisions about psychotropic medicine use during pregnancy and in breastfeeding on an individual basis, taking into account the woman's stage of pregnancy and, in particular, the risk of severe episodes of mental illness in relation to childbirth, the consequences for her family, the reproductive safety of medication and background risks of malformation, and the risk of neonatal withdrawal [National Collaborating Centre for Mental Health, 2014]. The advice to prescribe the lowest effective dose also reflects Canadian best practice guidelines [BC Reproductive Mental Health Program, 2014] and the opinion of the UK Teratology Information Service [UKTIS, 2017]. A British Association for Psychopharmacology consensus guideline advises generally avoiding switching medication in pregnancy unless the benefit outweighs the risks, and that the most important information about the efficacy of a drug for a particular woman is based on her own treatment history. If a woman has previously had a good response to a medication, there should be a good reason not to recommend it or to use a drug with unknown efficacy, even if it has a lower risk in pregnancy [McAllister-Williams et al, 2017].Risks of selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants (TCAs) and (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs]This information is largely based on a review of the available data by the UKTIS on the use of SSRIs, TCAs and (S)NRIs (duloxetine and venlafaxine) during pregnancy [UKTIS, 2016; UKTIS, 2017; UKTIS, 2018a; UKTIS, 2018b].UKTIS is recommended as a good source of information on specific drug use in pregnancy by a systematic review of recognition and management of perinatal depression and anxiety by general practitioners [Ford et al, 2017]. Information is also consistent with discussion of risks of SSRI and (S)NRI use in pregnancy in a British Association for Psychopharmocology consensus guidance [McAllister-Williams et al, 2017], a Canadian consensus guideline [MacQueen et al, 2016], a Medicines and Healthcare products Regulatory Agency guidance [MHRA, 2014], and meta-analyses of cohort and case-control studies [Mezzacappa et al, 2017; Zhang et al, 2017]. Back to top Follow up How should I follow-up a pregnant woman with depression? When following up a woman with depression in the antenatal or postnatal periods:Assess and agree the level of contact and support needed. Regularly monitor for symptoms during pregnancy and the postnatal period, particularly in the first few weeks after childbirth. At all contacts, consider asking the two depression identification questions as part of a general discussion about her mental health and wellbeing and using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of monitoring.At each postnatal contact, ask about the woman's emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Encourage women and their families/partners to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern. Discuss how her symptoms will be monitored, for example by using validated self-report questionnaires, such as the EPDS or PHQ-9. If a woman is on drug treatment, review frequently, with dose adjustment if necessary.Encourage postnatal women to help look after their mental health by looking after themselves, for example taking gentle exercise, resting, seeking help with caring for the baby, and talking to someone about how they are feeling.  Back to top Basis for recommendation Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence (NICE) publications Antenatal and postnatal mental health (clinical management and service guidance) [NICE, 2014] and Postnatal care up to 8 weeks after birth [NICE, 2006a]. The recommendation about frequent review of drug treatment is based on a consensus article on perinatal depression and anxiety [Kendig et al, 2017]. The recommendations are also supported by an evidence review commissioned by NICE which discussed that monitoring of the effects of interventions should be a continual process and incorporated into routine care, where possible [National Collaborating Centre for Mental Health, 2014].  Back to top Scenario: Postnatal: new episode Scenario: Postnatal woman: new episode From age 18 years to 60 years (Female). Back to top Making decisions about treatment What issues should I consider when making decisions about treatment? Before discussing the benefits and harms of treatment or starting, stopping, or switching antidepressant treatment for a postnatal woman, seek advice, ideally from a specialist perinatal mental health team, where available; or from secondary psychiatric care. Decisions about treating postnatal depression should be made on an individual basis. Involve the woman, and her family where appropriate, in all decisions about treatment, taking into account information on:The nature of her depression and severity of symptoms.Previous response to treatment.The options available and their risk, harms and benefits. The woman's relationships with, and level of support from, family or carers and the needs of her family (for example the welfare of her baby and other children). Discuss: Any particular concerns the woman has about her baby.Her plans regarding breastfeeding. Explain the benefits of breastfeeding and the risks associated with taking psychotropic medication when breastfeeding.The risks or harms to the woman of stopping antidepressants abruptly or changing treatment. The risks associated with not treating depression.The treatment options available to the woman (including psychological treatment, antidepressant treatment, or a combination of psychological and antidepressant treatment), including: The higher threshold for pharmacological interventions arising from the changing risk-benefit ratio for psychotropic medication at this time (particularly for breastfeeding women — note that no psychotropic medication has a UK marketing authorisation specifically for women who are pregnant or breastfeeding) and the likely benefits of a psychological intervention. The potential benefits of each treatment, considering the severity of the mental health problem.Treatment options that would enable the woman to breastfeed if she wishes. The risks or harms to the woman and her baby associated with each treatment option. Discuss the uncertainty about whether any problems for the woman or baby can be attributed directly to these drugs or may be caused by other factors.The uncertainty about the benefits, risks and harms of treatments for mental health problems in the postnatal period.The need for prompt treatment because of the potential effect of an untreated mental health problem on the baby.For more specific management information, see Managing depression in the postnatal period.   Back to top Basis for recommendation Basis for recommendation Seeking specialist adviceThis recommendation is extrapolated from the opinion of the National Institute for Health and Care Excellence (NICE) that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment is needed, or when psychotropic medication is started in the postnatal period [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].When considering the risk and benefit of antidepressant treatment for women considering breastfeeding, NICE also recommends taking into account the benefits of breastfeeding, uncertainty of the safety of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs] while breastfeeding, and the risks of stopping a previously effective medication, and advises seeking specialist advice for a breastfeeding woman if there is uncertainty about specific drugs [NICE, 2014]. The NICE guideline development group was of the opinion that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].  Decision makingThis recommendation is based on the NICE Antenatal and postnatal mental health: clinical management and service guideline [NICE, 2014] and the expert opinion of the NICE guideline development group, which advocated women being actively involved in decisions about their care [National Collaborating Centre for Mental Health, 2014]. The list of information to take into account also includes advice from a British Association for Psychopharmacology consensus guidance [McAllister-Williams et al, 2017] and Canadian best practice guidelines for mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014]. Areas for discussionThis recommendation largely reflects the NICE Antenatal and postnatal mental health: clinical management and service guideline, including the treatment options available to women and specific discussion points associated with them [NICE, 2014]. The National Collaborating Centre for Mental Health states that, for women with depression in pregnancy or the postnatal period, there should be a discussion about treatment options, including benefits and harms, and the potential consequences of abruptly stopping or changing drug treatment [National Collaborating Centre for Mental Health, 2014].    Risks of abrupt withdrawal of antidepressants — the Scottish Intercollegiate Guidelines Network (SIGN) advises that abrupt discontinuation of antidepressant treatment in women with serious mental illness who are at high risk of relapse is unwise, as relapse may ultimately be more harmful to the mother and child than continued drug treatment [SIGN, 2012]. NICE also emphasises the importance of not stopping medication without professional advice because of the risk of triggering or exacerbating an episode [NICE, 2016]. Risks of not treating depression — there is some evidence to suggest an increased risk of adverse outcomes for women with severe depression and their babies, including sudden infant death syndrome, and self harm [National Collaborating Centre for Mental Health, 2014]. Back to top Managing a new episode in the postnatal period How should I manage a new episode of depression in the postnatal period? Before discussing the benefits and harms of treatment or starting, stopping, or switching antidepressant treatment for a postnatal woman, seek advice, ideally from a specialist perinatal mental health team, where available; or from secondary psychiatric care. Discuss with a paediatrician if the woman wishes to breastfeed and the baby was premature or has health problems or liver or kidney impairment. For more information on the use of antidepressants in a postnatal or breastfeeding woman, see Prescribing an antidepressant in the postnatal period.For a woman with persistent subthreshold depressive symptoms, or mild to moderate depression, in the postnatal period, consider referral for facilitated self-help.For a woman with a history of severe depression who initially presents with mild depression in the postnatal period, consider a tricyclic antidepressant (TCA), selective serotonin reuptake inhibitor (SSRI), or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI].For a woman with moderate or severe depression in the postnatal period, consider the following options:Referral for a high-intensity psychological intervention (for example, CBT).A TCA, SSRI or (S)NRI if the woman understands the risks associated with the medication and the mental health problem in the postnatal period and:She has expressed a preference for medication, orShe declines psychological interventions, orHer symptoms have not responded to psychological interventionsReferral for a high-intensity psychological intervention in combination with medication if the woman understands the risks associated with the medication and the mental health problem in the postnatal period and there is no response, or a limited response, to a high-intensity psychological intervention or medication alone.Discuss treatment options that would enable a woman to breastfeed if she wishes and support women who choose not to breastfeed. If a woman is taking psychotropic medication while breastfeeding, monitor the baby for adverse effects.If the woman requires psychological treatment, ensure that she is assessed within 2 weeks of referral and is seen promptly for treatment (ideally, within 1 month of initial assessment).If a woman with depression decides to stop taking psychotropic medication in the postnatal period, monitor her mental status because of the risk of relapse. Discuss with her:Her reasons for stopping.The possibility of other options: for example having a psychological intervention, restarting medication if the depression is or has been severe and there has been a previous good response to treatment, or switching to other medication.Increasing her monitoring and support while she is not taking any medication.Any risks to herself, or the fetus or baby when stopping medication. Offer written information, for example the NHS Choices information on Postnatal depression (available at www.nhs.uk) or the Mind publication Understanding postnatal depression and perinatal mental health (available at www.mind.org.uk). Back to top Basis for recommendation Basis for recommendation The recommendations on management of a woman with postnatal depression are based mainly on Antenatal and postnatal mental health: clinical management and service guidance published by the National Institute for Health and Care Excellence (NICE) [NICE, 2014]. Seeking specialist adviceThis recommendation is extrapolated from the opinion of NICE that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment is needed, or when psychotropic medication is started in the postnatal period [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].The NICE guideline development group was of the opinion that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014]. Canadian guidelines advise discussion of psychotropic medication use (including antidepressants) with a paediatrician if women with babies who are premature or have significant health problems, or liver or kidney impairment want to breastfeed [BC Reproductive Mental Health Program, 2014; MacQueen et al, 2016].  Treating depression in postnatal and breastfeeding womenThe recommendations to treat postnatal depression depending on its severity are based mainly on the National Institute for Health and Care Excellence (NICE) publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014].A British Association for Psychopharmacology consensus guidance notes that drug treatment of postnatal depression does not markedly differ from depression at other times, but special consideration is needed for breastfeeding women [McAllister-Williams et al, 2017]. Advice from US and Canadian guidelines advise psychological therapies first-line for breastfeeding women as they do not cause any risk to the infant [Sriraman et al, 2015; MacQueen et al, 2016] and expert opinion in a review article pointed out a potential reluctance to take antidepressant medication in postnatal women, especially those who are breastfeeding [Jones and Shakespeare, 2014].Efficacy of non-pharmacological treatment in pregnancy and the postnatal periodThere is limited evidence for psychological treatments in postnatal women with mental health problems. When making its recommendations for women with varying severities of depression in pregnancy and the postnatal period, the NICE guideline development group (GDG) considered the evidence for the clinical and cost-effectiveness of facilitated self help and structured psychological interventions for the treatment of depression in non-pregnant women and also took into account the findings of an evidence review [National Collaborating Centre for Mental Health, 2014]:   Up to three studies (n = 1136) showed moderate clinical benefits of facilitated self help on the symptoms of depression compared with usual treatment in women with subthreshold to moderate symptoms of depression in pregnancy or the postnatal period (very low to high quality evidence).Up to ten studies showed large to moderate benefits with structured psychological interventions (CBT or IPT) in terms of depression diagnosis and symptoms (very low to high quality evidence), in addition to continued moderate to large effects in the short and intermediate term (low quality evidence).One study showed a large effect of structured psychological interventions on anxiety symptoms in women with depression (low quality evidence).For persistent subthreshold depressive symptoms, or mild to moderate depression, the GDG recommended considering facilitated self help and that its delivery should include written materials, support by a trained practitioner face-to-face or by telephone, and take place in usually six to eight sessions over a nine to twelve week period [National Collaborating Centre for Mental Health, 2014].For moderate to severe depression in pregnancy or the postnatal period, the GDG advised offering options in line with existing NICE guidance (taking into account the higher threshold for pharmcological treatment in pregnancy or breastfeeding), including structured psychological interventions (CBT or IPT) [National Collaborating Centre for Mental Health, 2014].A subsequent meta-analysis on the effectiveness of psychological interventions for postnatal depression in primary care included trials on CBT, IPT, counselling and support groups and found that psychological interventions produced lower levels of symptoms of depression in the longer term compared with control, (although the mean attrition rate was 23%) and higher levels of remission immediately following treatment [Stephens et al, 2016]. Efficacy of pharmacological treatment in pregnancy and the postnatal periodThere is good evidence of efficacy for pharmacological treatments for depression in the general population (see the NICE guideline Depression: the treatment and management of depression in adults [NICE, 2009] for more information). There is limited evidence regarding the efficacy of antidepressants in breastfeeding women; however, pharmacological treatments are not thought to have any differential benefit in pregnancy or the postnatal period compared with their use in other adult populations. The main difference at this time is the risk-benefit ratio [National Collaborating Centre for Mental Health, 2014].  An evidence review on the efficacy of pharmacological interventions for mental health problems in pregnancy and the postnatal period commissioned by NICE found [National Collaborating Centre for Mental Health, 2014]: One small study (n = 31) showing a moderate beneficial effect of mean depression scores when paroxetine was compared with placebo (very low quality evidence).Another study (n = 83) that found SSRIs had no statistically significant benefit compared with TCAs in terms of mean depression scores either post-treatment or at intermediate follow up (low quality evidence).Three studies (n = 188) indicating SSRIs combined with psychosocial interventions had a moderately beneficial effect on mean depression scores post intervention compared with placebo plus psychological interventions (low quality evidence).One study (n = 254) showing a moderate beneficial effect of antidepressants compared with general supportive care in terms of symptoms of depression (very low quality evidence).Monitor the baby for adverse effects if a woman is taking psychotropic medication while breastfeedingThis recommendation is consistent with US Academy of Breastfeeding Medicine advice that infants of breastfeeding mothers requiring antidepressant treatment should be monitored carefully, including growth [Sriraman et al, 2015]. The Specialist Pharmacy Service information on antidepressant safety in lactation recommends that when SSRIs or TCAs are used in breastfeeding women, infants should be monitored for drowsiness, poor feeding, irritability, restlessness, and behavioural effects [Specialist Pharmacy Service, 2016a; SPS, 2018].  Prompt treatment for women requiring psychological treatmentThe recommendation that psychological interventions for a pregnant or postnatal woman with a mental health problem should be provided within 1 month of intial assessment is based on Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014]. The Royal College of Psychiatrists also note that psychological therapy services (including Improving Access to Psychological Therapies [IAPT]) should ensure prompt assessment and treatment of perinatal women [Royal College of Psychiatrists, 2015].Reasons for the need for prompt intervention include [National Collaborating Centre for Mental Health, 2014]:  The potential impact of the woman's depression on the fetus or baby and her ability to function and care for herself and others in her family.Prioritisation of psychological interventions because of the higher threshold for drug treatments in the postnatal period (particularly breastfeeding), taking into account the altered risk-benefit ratio at this time. However, it is acknowledged that access to psychological treatments may be limited, creating challenges for perinatal services [National Collaborating Centre for Mental Health, 2014]. Stopping psychotropic medication in pregnancy and the postnatal periodThis recommendation is based on Antenatal and postnatal mental health: clinical management and service guidance, published by NICE [NICE, 2014] and Canadian best practice guidelines on mental health disorders in the perinatal period [BC Reproductive Mental Health Program, 2014]. Offering written informationCKS has based this recommendation on what it considers to be good clinical practice and the NICE recommendation to provide culturally relevant information on mental health problems in pregnancy and the postnatal period to the woman [NICE, 2014].  Back to top Referral and specialist advice When should I refer or seek specialist advice? Women who require admission for a mental health problem within 12 months of childbirth should ideally be admitted to a specialist mother and baby unit, unless there are specific reasons for not doing so. Admission of babies to general psychiatric wards is not advised.Refer to a secondary mental health service, ideally a specialist perinatal mental health service, for immediate assessment (within 4 hours of referral) if a woman has a sudden onset of symptoms suggestive of postpartum psychosis. Urgently refer to a secondary mental health team (ideally with a special interest in perinatal mental health) if a woman:Is severely depressed and presents a considerable immediate risk of harm to herself or other people — admission may be required if clinically indicated. Shows evidence of severe self-neglect or is unable to care for her infant. Has a possible diagnosis of bipolar disorder. For more information, see the CKS topic on Bipolar disorder. Has a history of severe mental illness, including postnatal depression, puerperal psychosis, or bipolar disorder (during pregnancy or the postnatal period or at any other time). Refer to a specialist substance misuse service if, in addition to depression, the woman has harmful or dependent drug or alcohol misuse in pregnancy or the postnatal period. Refer or seek specialist advice if:Considering starting, stopping, or switching antidepressant treatment for a postnatal or breastfeeding woman. The woman is not responding to treatment appropriate to the severity of her depression.Specialist advice may be sought ideally from a specialist perinatal mental health team where available, or from a secondary mental health service.Other factors to be taken into account when deciding whether to refer or seek specialist advice include:The woman's preference.The woman's past history and response to treatment.The degree of functional impairment.The presence of significant comorbidities or specific symptoms. Back to top Basis for recommendation Basis for recommendation Admission to a mother and baby unitThis reflects recommendations in the National Institute for Health and Care Excellence (NICE) publication Antenatal and postnatal mental health: clinical management and service guidance in relation to admission for mental health problems in general [NICE, 2014] and the Scottish Intercollegiate Guidelines Network (SIGN) guideline on Management of perinatal mood disorders [SIGN, 2012]. The Royal College of Psychiatrists also recommends women requiring admission to a mental health unit after delivery should be admitted with their baby to a specialist unit unless 'there are compelling reasons not to do so' [Royal College of Psychiatrists, 2015]. Immediate assessment if postpartum psychosis is suspectedThis recommendation is based on the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014] and is supported by expert opinion [Jones and Shakespeare, 2014; Langan and Goodbred, 2016].  Postpartum psychosis is a psychiatric emergency and will usually require admission to hospital because of its rapidly changing course and the risk of suicide or harm to the infant [Stewart and Vigod, 2016].Urgent referral These recommendations reflect referral advice in the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Recommendations have also been extrapolated from the NICE guidance Depression in adults: recognition and management [NICE, 2009] (although this is not specifically aimed at women in the antenatal or postnatal period). CKS has recommended the same diagnostic criteria for depression in the antenatal and postnatal periods, based on advice from the National Collaborating Centre for Mental Health to use usual diagnostic guidelines [National Collaborating Centre for Mental Health, 2014]. It would seem reasonable therefore to extrapolate referral advice to cover women who are depressed either antenatally or postnatally. The referral criteria also reflect expert opinion in clinical practice articles on peripartum and postpartum depression [Langan and Goodbred, 2016; Stewart and Vigod, 2016].  Referral to a specialist substance misuse serviceThis recommendation is based on the NICE publication Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014]. Referral or seeking advice on treatment decisionsThis recommendation is extrapolated from the opinion of NICE that advises considering seeking advice, preferably from a specialist perinatal mental health service, when psychotropic medication is started in the postnatal period [NICE, 2014]. It is also extrapolated from an evidence review commissioned by NICE that noted that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period. The NICE guideline development group was of the opinion that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].  When considering the risk and benefit of antidepressant treatment for women considering breastfeeding, NICE also recommends taking into account the benefits of breastfeeding, uncertainty of the safety of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and (serotonin-) noradrenaline reuptake inhibitors [(S)NRIs] while breastfeeding, and the risks of stopping a previously effective medication, and advises seeking specialist advice for a breastfeeding woman if there is uncertainty about specific drugs [NICE, 2014]. NICE recommends treating depression according to the severity of the episode [NICE, 2014]. If the treatment recommended by NICE for the severity of the woman's depression is not controlling symptoms, CKS recommends seeking specialist advice.Factors influencing the decision to referNICE advocates discussion with the woman about the risks and benefits of interventions, and her values and preferences in order for her to reach a fully informed decision and suggests also involving (with the woman's agreement) her partner, family or carer, in decision making [NICE, 2014]. Other factors are based on what CKS considers to be good clinical practice.  Back to top Prescribing an antidepressant in the postnatal period What should I consider before prescribing an antidepressant for a postnatal woman? Before discussing the benefits and harms of treatment or starting, stopping, or switching antidepressant treatment for a postnatal woman, seek advice, ideally from a specialist perinatal mental health team, where available; or from secondary psychiatric care. If choosing a selective serotonin reuptake inhibitor (SSRI), tricyclic antidepressant (TCA), or (serotonin-) noradrenaline reuptake inhibitor [(S)NRI] in the postnatal period: The choice of drug should be based on the woman's previous response to medication and the risk profile for her and baby. Note that no psychotropic medication has a UK marketing authorisation specifically for women who are breastfeeding and informed consent should be obtained and documented.The lowest effective dose should be prescribed, but ensure that depression is adequately treated. The risk of discontinuation symptoms in the woman should be taken into account.A single drug should be used, if possible, rather than two or more drugs.When assessing the risks and benefits of TCAs, SSRIs, or (S)NRIs for a woman who is considering breastfeeding, seek advice from a specialist (preferably from a specialist perinatal mental health service) if there is uncertainty about specific drugs and discuss with a paediatrician if the baby was premature or has health problems or liver or kidney impairment. The following should be taken into account: The benefits of breastfeeding for the woman and baby.The limited data and uncertainty about the safety of these drugs for the breastfeeding baby and the potential risks. The risks associated with switching from or stopping a previously effective medication.Provided the infant is healthy and his or her progress is monitored:Paroxetine and sertraline are the SSRIs of choice for a breastfeeding woman. Monitor infants for sedation, poor feeding and behavioural effects.Other SSRIs are not recommended but could be considered if the woman has been successfully treated with one of these drugs during pregnancy. Seek specialist advice.Tricyclic antidepressants (TCAs) are less commonly used than SSRIs for postnatal depression because of concerns about maternal toxicity. If clinically appropriate, imipramine and nortriptyline are preferred. Doxepin should be avoided. Monitor infants for drowsiness, poor feeding, and behavioural changes. For more information on antidepressants in breastfeeding, see the Specialist Pharmacy Service website for information on SSRIs, TCAs, and reboxetine, venlafaxine, duloxetine, mirtazapine, agomelatine and MAOIs (available at www.sps.nhs.uk), and the Drugs and Lactation Database (LactMed) (available at www.toxnet.nlm.nih.gov). Back to top Basis for recommendation Basis for recommendation These recommendations are largely based on the National Institute for Health and Care Excellence (NICE) Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014], a British Association for Psychopharmacology consensus guideline on the use of psychotropic medication preconception, in pregnancy, and postpartum [McAllister-Williams et al, 2017], and information on drugs in lactation from the Specialist Pharmacy Service.Seeking specialist advice on antidepressant treatment This recommendation is extrapolated from the opinion of NICE that advises considering seeking advice, preferably from a specialist perinatal mental health service, when more detailed advice about risks of mental health problems or the benefits and harms of treatment is needed, or when psychotropic medication is started in the postnatal period [NICE, 2014]. The opinion of the NICE guideline development group was that specialist knowledge is required when assessing the trade-off of the benefits and harms of psychotropic medication for mental health problems in pregnancy and the postnatal period and that considerable caution should be used when changing or stopping antidepressant drugs in pregnancy and the postnatal period [National Collaborating Centre for Mental Health, 2014].NICE advises that when choosing an antidepressant, prescribers should be aware that their safety in pregnancy and breastfeeding is not well understood  [National Collaborating Centre for Mental Health, 2014].Antidepressant choice in the postnatal periodThis recommendation is based on Antenatal and postnatal mental health: clinical management and service guidance published by the National Institute for Health and Care Excellence (NICE) [NICE, 2014].  The pharmacological treatment of depression postnatally is not substantially different to depression occurring at other times. However, special consideration is needed if a woman is breastfeeding [McAllister-Williams et al, 2017]. Assessing risks and benefits of antidepressants for a breastfeeding woman and her babyThis recommendation is based on Antenatal and postnatal mental health: clinical management and service guidance published by the National Institute for Health and Care Excellence (NICE) [NICE, 2014].There are no antidepressants licensed specifically for breastfeeding women [National Collaborating Centre for Mental Health, 2014]. However, if psychological treatment is unavailable or unacceptable to the woman, or symptoms are severe, antidepressants are an effective option [Sriraman et al, 2015] and medication will be an important therapeutic option for some breastfeeding women [National Collaborating Centre for Mental Health, 2014; McAllister-Williams et al, 2017].British Association of Psychopharmacology and Canadian guidelines advise caution around prescribing, and discussion of psychotropic medication use (including antidepressants) with a paediatrician if women with premature or sick babies want to breastfeed [BC Reproductive Mental Health Program, 2014; MacQueen et al, 2016; McAllister-Williams et al, 2017], and a Specialist Pharmacy Service summary advises that premature infants and those with respiratory depression should not be exposed to SSRIs via breast milk [Specialist Pharmacy Service, 2016a].  Choice of antidepressant for a breastfeeding womanSelective serotonin reuptake inhibitors (SSRIs)Paroxetine and sertraline are recommended by the Specialist Pharmacy Service as the SSRIs of choice for a breastfeeding woman because of their shorter half-lives and lower passage into milk [Specialist Pharmacy Service, 2016a; SPS, 2018]. The relatively long half lives of SSRIs means there is a risk of drug accumulation, particularly in neonates [Specialist Pharmacy Service, 2016a]. Although sertraline and paroxetine have the lowest reported levels of exposure, sertraline is the preferred option in breastfeeding, according to British Association for Psychopharmacology consensus guidance, due to paroxetine's greater risks of side effects and withdrawal problems [McAllister-Williams et al, 2017]. Tricyclic antidepressants (TCAs)Tricyclic antidepressants (TCAs) are less commonly used than SSRIs for postnatal depression because of concerns about maternal toxicity. If a TCA is appropriate, imipramine and nortriptyline are less sedating, although all tricyclic antidepressants, except doxepin, can be given to a breastfeeding woman if her infant is full term and healthy [SPS, 2018]. An infant ingests around 0.2-4% of the weight adjusted maternal daily dose. Doxepin should be avoided in breastfeeding women due to reports of adverse effects in the infant [MacQueen et al, 2016; Specialist Pharmacy Service, 2016b; Stewart and Vigod, 2016].  Other antidepressantsMonoamine oxidase inhibitors (MAOIs):  There are a lack of data on MAOI use in lactation. Because of this and their potential to cause serious interactions with some foods and drugs (for example some analgesics and anaesthetic agents), first generation MAOIs should be avoided during breastfeeding and moclobemide is not considered to be a first-line option for breastfeeding women [MacQueen et al, 2016; SPS, 2018]. Reboxetine, venlafaxine, duloxetine, and mirtazapine are not considered first line antidepressants for use in breastfeeding mothers. Limited data indicate that reboxetine, duloxetine, and mirtazapine pass into breast milk in small amounts, with estimated infant intake via breast milk calculated at values of up to 2% of the weight adjusted maternal dose (3.5–9.2% for venlafaxine) [Specialist Pharmacy Service, 2016c; Stewart and Vigod, 2016].St John's wort should be avoided by women who are breastfeeding as there are only limited data available on its safety [SPS, 2016].Considering a previously used SSRI The UK Specialist Pharmacy Service advise that if a woman has had successful treatment with an SSRI during pregnancy and it is also needed postnatally, the drug does not need to be changed if the baby is full term, healthy and adequately monitored [Specialist Pharmacy Service, 2016a]. Expert opinion in a clinical practice article notes that this approach reduces the risk of relapse compared with switching antidepressant treatment [Stewart and Vigod, 2016].A British Association of Psychopharmacology consensus guideline acknowledges the choice of antidepressant when breastfeeding should take into account a woman's previous response to medication, and states the risks in breastfeeding of antidepressants other than sertraline may be outweighed by their advantages for continuation treatment [McAllister-Williams et al, 2017].CKS recommends seeking specialist advice on continuing existing treatment in line with the NICE recommendation to consider seeking more detailed advice on the benefits and harms of treatment in pregnancy and the postnatal period [NICE, 2014], particularly as individual SSRIs have different levels of risk in breastfeeding [SPS, 2018].  Back to top Follow up How should I follow-up a postnatal woman with depression? When following up a woman with depression in the antenatal or postnatal periods:Assess and agree the level of contact and support needed. Regularly monitor for symptoms during pregnancy and the postnatal period, particularly in the first few weeks after childbirth. At all contacts, consider asking the two depression identification questions as part of a general discussion about her mental health and wellbeing and using the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire (PHQ-9) as part of monitoring.At each postnatal contact, ask about the woman's emotional wellbeing, what family and social support they have and their usual coping strategies for dealing with day-to-day matters. Encourage women and their families/partners to tell their healthcare professional about any changes in mood, emotional state and behaviour that are outside of the woman's normal pattern. Discuss how her symptoms will be monitored, for example by using validated self-report questionnaires, such as the EPDS or PHQ-9. If a woman is on drug treatment, review frequently, with dose adjustment if necessary.Encourage postnatal women to help look after their mental health by looking after themselves, for example taking gentle exercise, resting, seeking help with caring for the baby, and talking to someone about how they are feeling.  Back to top Basis for recommendation Basis for recommendation These recommendations are based on the National Institute for Health and Care Excellence (NICE) publications Antenatal and postnatal mental health (clinical management and service guidance) [NICE, 2014] and Postnatal care up to 8 weeks after birth [NICE, 2006a]. The recommendation about frequent review of drug treatment is based on a consensus article on perinatal depression and anxiety [Kendig et al, 2017].  The recommendations are also supported by an evidence review commissioned by NICE which discussed that monitoring of the effects of interventions should be a continual process and incorporated into routine care, where possible [National Collaborating Centre for Mental Health, 2014].  Prescribing information Back to topPrescribing information Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC), or the British National Formulary (BNF). Back to top Prescribing antidepressants What should I be aware of before prescribing an antidepressant for a woman who is pregnant or breastfeeding? If a woman becomes pregnant when taking an antidepressant, or before starting, stopping, or switching antidepressant treatment during pregnancy or the postnatal period, seek advice, ideally from a specialist perinatal mental health team, where available; or from secondary psychiatric care, or the UK Teratology Information Service (UKTIS) on 0344 892 0909. Note that no psychotropic medication has a UK marketing authorisation specifically for women who are pregnant or breastfeeding and informed consent should be obtained and documented.For antidepressant prescribing information specific to pregnancy, the postnatal period, and breastfeeding, see the scenarios Pregnant woman: on an antidepressant, Pregnant woman: new episode, and Postnatal woman: new episode.  For general contraindications, cautions, adverse effects and drug interactions of antidepressants, see the Prescribing information section in the CKS topic on Depression.  Supporting evidence Back to topSupporting evidence This CKS topic is largely based on the National Institute for Health and Care Excellence (NICE) Antenatal and postnatal mental health: clinical management and service guidance [NICE, 2014] and associated evidence review [National Collaborating Centre for Mental Health, 2014]. The rationale for the diagnosis, assessment, referral, and primary care management of women with depression in pregnancy or the postnatal period is outlined in the relevant basis for recommendation sections of the topic. How this topic was developed Back to topHow this topic was developed This section briefly describes the processes used in developing and updating this topic. Further details on the full process can be found in the About Us section and on the Clarity Informatics website. Back to top Search strategy Search strategy Scope of searchA literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of depression - antentatal and postnatal.Search datesDecember 2012 - September 2018Key search termsVarious combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline.exp Puerperal Disorders/, (puerperal adj psychosis).tw., (post-natal adj depression).tw., (postnatal adj depression).tw., (postpartum adj depression).tw., post partum depression.tw., post-partum depression.tw., antenatal depression.tw., perinatal depression.tw., prenatal depression.tw., pre-natal depression.tw.Sources of guidelines National Institute for Health and Care Excellence (NICE) Scottish Intercollegiate Guidelines Network (SIGN) Royal College of Physicians Royal College of General Practitioners Royal College of Nursing NICE Evidence Health Protection Agency World Health Organization National Guidelines Clearinghouse Guidelines International Network TRIP database GAIN NHS Scotland National Patient Pathways New Zealand Guidelines Group Agency for Healthcare Research and Quality Institute for Clinical Systems Improvement National Health and Medical Research Council (Australia) Royal Australian College of General Practitioners British Columbia Medical Association Canadian Medical Association Alberta Medical Association University of Michigan Medical School Michigan Quality Improvement Consortium Singapore Ministry of Health National Resource for Infection Control Patient UK Guideline links UK Ambulance Service Clinical Practice Guidelines RefHELP NHS Lothian Referral Guidelines Medline (with guideline filter) Driver and Vehicle Licensing Agency NHS Health at Work(occupational health practice)Sources of systematic reviews and meta-analyses The Cochrane Library: Systematic reviews Protocols Database of Abstracts of Reviews of Effects Medline (with systematic review filter) EMBASE (with systematic review filter)Sources of health technology assessments and economic appraisals NIHR Health Technology Assessment programme The Cochrane Library: NHS Economic Evaluations Health Technology Assessments Canadian Agency for Drugs and Technologies in Health International Network of Agencies for Health Technology AssessmentSources of randomized controlled trials The Cochrane Library: Central Register of Controlled Trials Medline (with randomized controlled trial filter) EMBASE (with randomized controlled trial filter)Sources of evidence based reviews and evidence summaries Bandolier Drug & amp; Therapeutics Bulletin TRIP database Central Services Agency COMPASS Therapeutic NotesSources of national policy Department of Health Health Management Information Consortium(HMIC)Patient experiences Healthtalkonline BMJ - Patient Journeys Patient.co.uk - Patient Support GroupsSources of medicines informationThe following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content. British National Formulary(BNF) electronic Medicines Compendium(eMC) European Medicines Agency(EMEA) LactMed Medicines and Healthcare products Regulatory Agency(MHRA) REPROTOX Scottish Medicines Consortium Stockley's Drug Interactions TERIS TOXBASE Micromedex UK Medicines Information Back to top Stakeholder engagement Stakeholder engagement Our policyThe external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:Clinical accuracy.Consistency with other providers of clinical knowledge for primary care.Accuracy of implementation of national guidance (in particular NICE guidelines).Usability.Principles of the consultation processThe process is inclusive and any individual may participate.To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.External reviewers are not paid for commenting on the draft topics.Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.All reviewers are invited to be acknowledged on the website.All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.StakeholdersKey stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.Stakeholders identified from the following groups are invited to review draft topics:Experts in the topic area.Professional organizations and societies(for example, Royal Colleges).Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer's Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.Guideline development groups where the topic is an implementation of a guideline.The British National Formulary team.The editorial team that develop MeReC Publications.Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.Patient engagementClarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:Topic selectionScoping of topicSelection of clinical scenariosFirst draft internal reviewSecond draft internal reviewExternal reviewFinal draft and pre-publicationOur lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals. Back to top Evidence exclusion criteria Evidence exclusion criteria Our policyScoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.Standard exclusions for scoping literature:Animal studiesOriginal research is not written in EnglishPossible exclusions for reviewed literature:Sample size too small or study underpoweredBias evident or promotional literaturePopulation not relevantIntervention/treatment not relevantOutcomes not relevantOutcomes have no clear evidence of clinical effectivenessSetting not relevantNot relevant to UKIncorrect study typeReview articleDuplicate reference Back to top Organizational, behavioural and financial barriers Organizational, behavioural and financial barriers Our policyThe CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.FeasibilityStudies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.Organizational and Financial Impact AnalysisStudies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.Eligible populationCurrent interventionsLikely uptake of new intervention or recommendationCost of the current or new intervention mixImpact on other costsCondition-related costsIn-direct costs and service impactsTime dependenciesCost-effectiveness or cost-benefit analysis studies are identified where available. We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation. Back to top Declarations of interest Declarations of interest Our policyClarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:Personal financial interestsPersonal family interestPersonal non-financial interestNon-personal financial gain or benefitAlthough particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons.An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.Who should declare competing interests?Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.Competing interests declared for this topic:None. References Back to topReferences American Psychiatric Association (Eds.) (2013) Diagnostic and statistical manual of mental disorders: DSM-5. Washington, DC: American Psychiatric Association.. Anderson, I.M. and Nutt, D.J. and Deakin, J.F.W. (2000) Vidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 1993 British Association for Psychopharmacology guidelines. Journal of Psychopharmacology. 14(1), 3-20. [Abstract] Baxter,K. (Eds.) (2010) Stockley's drug interactions 2010: pocket companion. London: Pharmaceutical Press.. BC Reproductive Mental Health Program and Perinatal Services BC (2014) Best practice guidelines for mental health disorders in the perinatal period. BC Reproductive Mental Health Program. reproductivementalhealth.ca [Free Full-text] BMA and NHS Employers (2018) Summary of changes to QOF 2018/19. NHS. www.nhsemployers.org [Free Full-text] Brockington, I., Butterworth, R. and Glangeaud-Freudenthal, N. (2017) An international position paper on mother-infant (perinatal) mental health, with guidelines for clinical practice. Archives of women's mental health 20(1), 113-120. [Abstract] [Free Full-text] Craig,M. and Howard,L. (2009) Postnatal depression. Clinical Evidence. BMJ Publishing Group Ltd.. www.clinicalevidence.com [Free Full-text] CSM (2000) Selective serotonin reuptake inhibitors (SSRIs). Current Problems in Pharmacovigilance. 26(Sep), 11-12. CSM (2004) Reminder: Paroxetine prescribing advice. 30(Oct), 3. Dalton, S.O., Johansen, C. and Mellemkjaer, L. et al. (2003) Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study. Archives of Internal Medicine. 163(1), 59-94. [Abstract] [Free Full-text] de Abajo,F.J., Rodriguez,L.A.G. and Montero,D. (1999) Association between selective serotonin reuptake inhibitors and upper gastrointestinal bleeding: population based case-control study. 319(7217), 1106-1109. [Abstract] Dennis,C.L. and Hodnett,E. (2007) Psychosocial and psychological interventions for treating postpartum depression (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text] Dennis,C.L. and Stewart,D.E. (2004) Treatment of postpartum depression, part 1: a critical review of biological interventions. 65(9), 1242-1251. [Abstract] Dennis,C.L., Ross,L.E. and Grigoriadis,S. (2007) Psychosocial and psychological interventions for treating antenatal depression (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text] DVLA (2012) At a glance guide to the current medical standards of fitness to drive. Driver and Vehicle Licensing Agency.. www.gov.uk [Free Full-text] Ford, E., Shakespeare, J. and Elias, F. et al (2017) Recognition and management of perinatal depression and anxiety by general practitioners: a systematic review. Family practice 34(1), 11-19. [Abstract] Haddad,P.M. (2001) Antidepressant discontinuation syndromes. Drug Safety. 24(3), 183-197. [Abstract] Henshaw,C (2013) Personal communication. Consultant in Perinatal Mental Health, Liverpool Women's NHS Foundation Trust: Liverpool. Hoffbrand, S. and Howard, L. and Crawley, H. (2001) Antidepressant treatment for post-natal depression (Cochrane Review). John Wiley & Sons, Ltd. www.cochranelibrary.com/ [Free Full-text] Jones, I. and Shakespeare, J. (2014) Postnatal depression. BMJ 349, g4500. [Abstract] Kendig, S., Keats, J.P. and Hoffman, M.C. et al (2017) Consensus bundle on maternal mental health: perinatal depression and anxiety. Obstetrics and gynecology 129(3), 422-430. [Abstract] [Free Full-text] Langan, R. and Goodbred, A.J. (2016) Identification and management of peripartum depression. American family physician 93(10), 852-858. [Abstract] [Free Full-text] Lundbeck Ltd (2011) Association of CIPRAMIL ® (citalopram hydrobromide) with dose-dependent QT interval prolongation. Medicines and Healthcare products Regulatory Agency.. www.mhra.gov.uk [Free Full-text] MacQueen, G.M., Frey, B.N. and Ismail, Z. et al (2016) Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: Section 6. special populations: youth, women, and the elderly. Canadian journal of psychiatry 61(9), 588-603. [Abstract] [Free Full-text] Mason,J., Freemantle,N. and Eccles,M. (2000) Fatal toxicity associated with antidepressant use in primary care. 50(454), 366-370. [Abstract] McAllister-Williams, R.H., Baldwin, D.S., Cantwell, R. and et al (2017) British Association for Psychopharmacology consensus guidance on the use of psychotropic medication preconception, in pregnancy and postpartum 2017. Journal of psychopharmacology. 31(5), 519-552. [Abstract] Mead,G.E., Morley,W., Campbell,P., et al. (2009) Exercise for depression (Cochrane Review). The Cochrane Library. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text] Meijer, W.E., Heerdink, E.R. and Nolen, W.A. et al. (2004) Association of risk of abnormal bleeding with degree of serotonin reuptake inhibition by antidepressants. Archives of Internal Medicine. 164(21), 2367-2370. [Abstract] [Free Full-text] Mezzacappa, A., Lasica, P.A. and Gianfagna, F. et al (2017) Risk for autism spectrum disorders according to a period of prenatal antidepressant exposure: A systematic review and meta-analysis. JAMA pediatrics 171(6), 555-563. [Abstract] [Free Full-text] MHRA (2010) Fluoxetine: possible small risk of congenital cardiac defects, similar to that with paroxetine. Drug Safety Update. 3(8), 4. MHRA (2014) Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs): use and safety. Medicines and Healthcare products Regulatory Agency. www.gov.uk [Free Full-text] Molyneaux, E., Howard, L.M. and McGeown, H.R. et al (2014) Antidepressant treatment for postnatal depression (Cochrane Review). John Wiley & Sons, Ltd.. www.cochranelibrary.com/ [Free Full-text] National Collaborating Centre for Mental Health (2007) Antenatal and postnatal mental health: the NICE guideline on clinical management and service guidance (full NICE guideline). National Institute for Health and Clinical Excellence.. www.nice.org.uk [Free Full-text] National Collaborating Centre for Mental Health (2010) Depression. The NICE guideline on the treatment and management of depression in adults (updated edition). The British Psychological Society and the Royal College of Psychiatrists. www.nice.org.uk [Free Full-text] National Collaborating Centre for Mental Health (2014) Antenatal and postnatal mental health. The NICE guideline on clinical management and service guidance (updated edition). The British Psychological Society and the Royal College of Psychiatrists. www.nice.org.uk [Free Full-text] NHS England, NHS Improvement, National Collaborating Centre for Mental Health (2018) The perinatal mental health care pathways. NHS England and NHS Improvement. www.england.nhs.uk [Free Full-text] NICE (2006) Computerised cognitive behaviour therapy for depression and anxiety: review of technology appraisal 51 (NICE technology appraisal 97). National Institute of Health and Clinical Excellence.. www.nice.org.uk [Free Full-text] NICE (2006a) Postnatal care up to 8 weeks after birth (updated February 2015). National Institute for Health and Care Excellence.. www.nice.org.uk [Free Full-text] NICE (2007) Antenatal and postnatal mental health. Clinical management and service guidance. National Institute for Health and Clinical Excellence.. www.nice.org.uk [Free Full-text] NICE (2009) Depression. The treatment and management of depression in adults (NICE guideline). National Institute for Health and Clinical Excellence.. www.nice.org.uk [Free Full-text] NICE (2013) Postnatal care (NICE Quality Standard). NICE Quality Standard [QS37]. National Institute for Health and Care Excellence.. www.nice.org.uk/ [Free Full-text] NICE (2014) Antenatal and postnatal mental health: clinical management and service guidance. National Institute for Health and Care Excellence.. www.nice.org.uk [Free Full-text] NICE (2016) Antenatal and postnatal mental health. Quality standard (QS115). National Institute for Health and Care Excellence. www.nice.org.uk [Free Full-text] NTIS (2005) Treatment of depression in pregnancy. TOXBASE. National Teratology Information Service.. www.toxbase.org O'Connor, E., Rosson, R.C. and Henninger, M. et al (2016) Primary care screening for and treatment of depression in pregnant and postpartum women: Evidence report and systematic review for the US preventive services task force. JAMA 315(4), 388-406. [Abstract] [Free Full-text] Paton,C. and Ferrier,I.N. (2005) SSRIs and gastrointestinal bleeding. 331(7516), 529-530. Royal College of General Practitioners (2016) Position statement about perinatal mental health. Royal College of General Practitioners. www.rcgp.org.uk Roose, S.P. and Spatz, E. (1999) Treating depression in patients with ischaemic heart disease: which agents are best to use and to avoid?. Drug Safety. 20(5), 459-465. [Abstract] Ross,L.E. and Dennis,C.L. (2009) The prevalence of postpartum depression among women with substance use, an abuse history, or chronic illness: a systematic review. Journal of Women's Health. 18(4), 475-486. [Abstract] Royal College of Psychiatrists (2015) Perinatal mental health services. Recommendations for the provision of services for childbearing women. Royal College of Psychiatrists. www.rcpsych.ac.uk [Free Full-text] Schaefer,C., Peters,P., Miller,R.K. (Eds.) (2007) Drugs during pregnancy and lactation: treatment options and risk assessment. edn. Oxford: Academic Press. SIGN (2002) Postnatal depression and puerperal psychosis. Scottish Intercollegiate Guidelines Network.. www.sign.ac.uk [Free Full-text] SIGN (2010) Non-pharmaceutical management of depression in adults. Scottish Intercollegiate Guidelines Network.. www.sign.ac.uk [Free Full-text] SIGN (2012) Management of perinatal mood disorders. A national clinical guideline. Scottish Intercollegiate Guidelines Network.. www.sign.ac.uk [Free Full-text] Specialist Pharmacy Service (2016a) Management of depression in breastfeeding mothers – are selective serotonin reuptake inhibitors (SSRIs) safe?. Specialist Pharmacy Service. www.sps.nhs.uk [Free Full-text] Specialist Pharmacy Service (2016b) Management of depression in breastfeeding mothers - are tricyclic antidepressants safe?. Specialist Pharmacy Service. www.sps.nhs.uk [Free Full-text] Specialist Pharmacy Service (2016c) Management of depression in breastfeeding mothers - are reboxetine, venlafaxine, duloxetine, mirtazapine, agomelatine and MAOIs safe?. Specialist Pharmacy Service. www.sps.nhs.uk [Free Full-text] SPS (2016) Management of depression in breastfeeding mothers - Are St. John's Wort and other complementary therapies safe?. Specialist Pharmacy Service. www.sps.nhs.uk [Free Full-text] SPS (2018) Safety in lactation: antidepressants. Specialist pharmacy service. www.sps.nhs.uk [Free Full-text] Sriraman, N.K., Melvin, K. and Meltzer-Brody, S. (2015) ABM clinical protocol 18: Use of antidepressants in breastfeeding mothers. Breastfeeding medicine 10(6), 290-299. [Abstract] [Free Full-text] Stephens, S., Ford, E. and Paudyal, P. et al (2016) Effectiveness of psychological interventions for postnatal depression in primary care: a meta-analysis. Annals of family medicine 14(5), 463-472. [Abstract] [Free Full-text] Stewart, D.E. and Vigod, S. (2016) Postpartum depression. New England journal of medicine 375(22), 2177-2186. [Abstract] Taylor,D., Paton,C. and Kapure,S. (2012) The Maudsley prescribing guidelines.11th edn. London: Informa Healthcare. Taylor, M.J., Freemantle, N. and Geddes, J.R. and Bhagwagar, Z. (2006) Arly onset of selective serotonin reuptake inhibitor antidepressant action: systematic review and meta-analysis. Archives of General Psychiatry. 63(11), 1217-1223. [Abstract] [Free Full-text] UKTIS (2010) Use of trazodone in pregnancy. UK Teratology Information Service.. www.toxbase.org/ UKTIS (2010) Use of amitriptyline in pregnancy. TOXBASE. UK Teratology Information Service.. www.toxbase.org UKTIS (2011) Use of fluoxetine in pregnancy. TOXBASE. UK Teratology Information Service.. www.uktis.org [Free Full-text] UKTIS (2011) Use of selective serotonin reuptake inhibitors in pregnancy. TOXBASE. UK Teratology Information Service.. www.uktis.org [Free Full-text] UKTIS (2011) Use of escitalopram in pregnancy. TOXBASE. UK Teratology Information Service.. www.toxbase.org UKTIS (2011) Use of paroxetine in pregnancy. TOXBASE. UK Teratology Information Service.. www.uktis.org UKTIS (2012) Use of dosulepin in pregnancy. UK Teratology Information Service.. [Free Full-text] UKTIS (2012) Use of sertraline in pregnancy. UK Teratology Information Service.. www.toxbase.org/ UKTIS (2013) UKTIS information summaries. UK Teratology Information Service.. www.uktis.org [Free Full-text] UKTIS (2016) Use of venlafaxine in pregnancy. UK Teratology Information Service. www.uktis.org [Free Full-text] UK Teratology Information Service (2017) Use of selective serotonin reuptake inhibitors in pregnancy. UKTIS. www.uktis.org [Free Full-text] UKTIS (2018a) Use of duloxetine in pregnancy. UK Teratology Information Service. www.uktis.org [Free Full-text] UKTIS (2018b) Use of tricyclic antidepressants in pregnancy. UK Teratology Information Service. www.uktis.org [Free Full-text] van der Zee-van den Berg, A.I., Boere-Boonekamp, M.M. and IJzerman, M.J. et al (2017) Screening for postpartum depression in well-baby care settings: a systematic review. Maternal and child health journal 21(1), 9-20. [Abstract] [Free Full-text] van Walraven, C., Mamdani, M.M. and Wells, P.S. and Williams, J.I. (2001) Inhibition of serotonin reuptake by antidepressants and upper gastrointestinal bleeding in elderly patients: retrospective cohort study. British Medical Journal. 323(7314), 655-660. [Abstract] [Free Full-text] Zhang, T.N., Gao, S.Y. and Shen, Z.Q. et al (2017) Use of selective serotonin-reuptake inhibitors in the first trimester and risk of cardiovascular-related malformations: a meta-analysis of cohort studies. Scientific reports 7, 43085. [Abstract] [Free Full-text]